Enhanced recovery after surgery (ERAS) in gynecology oncology

Enhanced recovery after surgery continuity nursing in elderly gastric cancer patients

BACKGROUND

Gastric cancer predominantly affects the elderly, who face significant challenges due to high postoperative complications and stress. These challenges include comorbidities, reduced physiological reserves, and increased risks of infections and delayed healing. Traditional postoperative care often falls short in addressing these issues effectively. Enhanced recovery after surgery (ERAS) principles have revolutionized surgical care by reducing stress and promoting recovery through a holistic approach. ERAS emphasizes preoperative optimization, intraoperative care, and postoperative rehabilitation tailored to patient needs. Despite its recognized benefits, the impact of continuity nursing care within the ERAS framework on elderly gastric cancer patients remains underexplored. This study examines the influence of ERAS-based continuity nursing care on postoperative satisfaction, inflammation, stress, and quality of life in elderly patients undergoing gastric cancer resection.

AIM

To investigate the effects of ERAS-based continuity nursing care on postoperative satisfaction, inflammation, stress, and quality of life in elderly gastric cancer patients.

METHODS

A retrospective cohort analysis was conducted on 322 elderly patients who underwent gastric cancer resection between January 2020 and January 2022. Patients were assigned to a routine care group (n = 156) or an ERAS-control (ERAS-C) group (n = 166). Data collected included demographic information, inflammatory and stress markers, satisfaction scores using the patient satisfaction questionnaire-18, and quality of life measured using the European Organization for Research and Treatment of Cancer 22-item quality of life questionnaire specific to gastric cancer.

RESULTS

The ERAS-C group exhibited significantly lower postoperative interleukin-6 levels than the routine care group (12.97 ± 4.02 pg/mL vs 14.37 ± 3.86 pg/mL; P = 0.002). This finding indicates that the ERAS-C group experienced reduced inflammation. The ERAS-C group also had a higher cluster of differentiation (CD) 4:CD8 ratio than the routine care group (2.34 ± 0.35 vs 2.13 ± 0.61; P < 0.001), suggesting the former’s enhanced immune response. Postoperative stress markers, including norepinephrine, cortisol, and aldosterone, were significantly lower in the ERAS-C group than in the routine care group (P < 0.05 for all). Compared with the routine care group, the ERAS-C group showed increased nursing satisfaction scores (80.36 ± 7.24 vs 75.23 ± 7.03; P < 0.001) and improved quality of life indicators, such as reduced dysphagia and pain, (P < 0.05). The ERAS-C group also experienced fewer complications than the routine care group (5.42% vs 11.54%, P = 0.048).

CONCLUSION

Continuity nursing care within the ERAS framework significantly enhances postoperative outcomes for elderly gastric cancer patients by reducing inflammation, stress, and complications while improving satisfaction and quality of life.

Multimodal Prehabilitation in Colorectal Cancer: Improving Fitness, Lifestyle, and Post-Surgery Outcomes

Objectives: This study aimed to analyze the effect of a multimodal prehabilitation program for colorectal cancer patients in body composition, physical and cardiorespiratory fitness as well as its ability to reduce postoperative complications. Methods: A longitudinal observational study evaluated the efficacy of a prehabilitation intervention based on four components: (a) health education and self-care, (b) nutritional counseling, (c) psychological support, and (d) supervised physical exercise. Body composition was determined through bioelectrical impedance analysis; physical fitness variables such as strength was measured by a handgrip dynamometer for upper limbs, and a squat-jump test, countermovement jump test using a contact platform, and a chair-stand test for lower limbs. Flexibility was assessed with the sit-and-reach test. Cardiorespiratory fitness was assessed with the 6 min walking test (6MWT). Moreover, we measured lifestyles related to the amount of physical exercise by accelerometry. Results: The final cohort included 30 patients. Patients completed an average of 9.90 ± 5.26 exercise sessions. Statistically significant changes with varying effect sizes were observed in the following outcomes: SJ values in cm and W for both sexes (p = 0.021/d = 0.14 and p = 0.043/d = 0.10, respectively), SJ in W for women (p = 0.023/d = 0.21), all chair-stand test values (p = 0.021/d = 0.65 for men, p = 0.004/d = 2.08 for women, and p = 0.000/d = 0.84 for both sexes), and sit-and-reach for both sexes (p = 0.005/d = 0.12) and for men (p = 0.044/d = 0.08). All 6MWT values had statistically significant changes (p = 0.001/0.46). Women reduced the weekly minutes spent in sedentary behavior (p = 0.037/d = 0.65) and increased the minutes spent performing light physical activity (p = 0.037/d = 0.63). With regard to surgical outcomes, there was a tendency towards a decrease in postoperative complications and hospitalization days, as well as minutes in postoperative REA (p = 0.009/d = 0.69) in relation to the control group. Conclusions: Participation in a multimodal prehabilitation program improves several aspects of physical condition and lifestyles related to the amount of physical exercise and reduces both days of hospitalization and several complications post-surgery.

Efficacy of Perioperative Application of Enhanced Recovery After Surgery on Elderly Recipients Underwent Liver Transplantation

BACKGROUND

Primary liver cancer, predominantly hepatocellular carcinoma (HCC), is a major global health concern. Liver transplantation is a critical therapeutic option for HCC, offering potential tumor eradication and cure of underlying liver disease. Enhanced Recovery After Surgery (ERAS) protocols aim to improve patient outcomes by optimizing perioperative care. This study evaluates the efficacy of ERAS in elderly liver transplant recipients.

METHODS

A retrospective study was conducted on elderly liver transplant patients treated from January 2016 to March 2023. Patients were divided into two groups: conventional care (n = 58) and ERAS-based care (n = 57). Propensity score matching controlled for confounding variables. Perioperative care interventions included preoperative education, intraoperative management, and postoperative strategies emphasizing early mobilization, pain management, and nutrition. Outcomes included postoperative recovery times, complication rates, and anxiety levels.

RESULTS

ERAS group patients showed significantly improved recovery metrics: reduced times to first oral intake (29.26 vs. 38.42 h, p = 0.011), first ambulation (3.93 vs. 5.46 days, p = 0.008), and first flatus (3.07 vs. 4.33 days, p = 0.003). ICU and total hospital stays were shorter (2.89 vs. 4.52 days, p = 0.007; 22.18 vs. 27.14 days, p = 0.014). The ERAS group had lower complication rates (31.6% vs. 56.9%, p = 0.009) and reduced anxiety levels.

CONCLUSION

ERAS protocols significantly enhance postoperative recovery and reduce complications in elderly liver transplant recipients. These findings support the integration of ERAS principles into liver transplantation care to improve patient outcomes.

Optimizing maternal recovery: insights into enhanced recovery after Cesarean delivery

Enhanced recovery after surgery (ERAS) is an innovative perioperative management approach designed to shorten the recovery time, improve patient safety and quality of care, and enhance overall satisfaction. Successful implementation of ERAS requires active collaboration between healthcare providers and patients to facilitate a timely return to daily activities. The ERAS protocol, originally developed for colorectal surgery, has gradually been expanded and adapted to other major surgeries, and more recently, to Cesarean deliveries. Enhanced recovery after Cesarean delivery (ERAC) presents unique challenges due to its distinct patient population, comprising relatively young women. Its dual focus on maternal recovery and neonatal well-being sets it apart from conventional ERAS protocols. Several components of the ERAC protocol have been adapted from the ERAS recommendations; however, supporting evidence remains limited. This review examines the current ERAC protocol and considers the types of research needed to establish an evidence-based ERAC protocol in the future.

Implementation of enhanced recovery in women undergoing cesarean delivery improves breastfeeding and maternal perioperative outcomes

The study aimed to evaluate delivery outcomes after implementation of the Enhanced Recovery After Surgery (ERAS) protocol in patients delivered by cesarean section (CD).This randomized controlled prospective study was conducted on 78 pregnant women who underwent CD with the ERAS protocol and 78 pregnant women who under went standard perioperative care. We compared the time to first flatus, visual pain score (VAS), the success of breastfeeding, time to initiation of breastfeeding, time to return to daily activities, hemoglobin values, the incidence of postoperative nausea and vomiting, hospital readmission rates, postoperative wound infection rates, incidence of postpartum blues, and the need for blood transfusion between two groups.Time to first flatus, VAS score, time to initiation of breastfeeding, and time to return to activities of daily living were significantly lower in the ERAS group (p<0.001 for all). The rate of successful breastfeeding was significantly higher in the ERAS group (p<0.001). Both groups were similar in terms of other parameters.Implementation of ERAS after CD shortens the breastfeeding initiation time and increases rates of successful breastfeeding. ERAS protocols implemented in CD improve perioperative outcomes such as visual pain score and time to resume daily activities.

Wound Infiltration With Local Anesthetics Versus Transversus Abdominis Plane Block for Postoperative Pain Management in Gynecological Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Postoperative pain management significantly influences recovery speed, hospital stay duration, and healthcare costs. In light of inconsistencies in clinical trial outcomes, we conducted a systematic review and meta-analysis to assess the efficacy of the Transversus Abdominis Plane (TAP) block compared to local anesthetic wound infiltration (WI) for postoperative pain management in gynecological surgery.

DATA SOURCES

Systematic searches were conducted across PubMed/MEDLINE, ScienceDirect, the Cochrane Library, and Web of Science databases to identify all randomized controlled trials comparing TAP block and WI in adult patients undergoing gynecological surgical procedures. Additionally, the reference lists of the identified studies were manually reviewed. Only studies published in English were eligible for inclusion in the analysis.

METHODS OF STUDY SELECTION

The Population, Intervention, Comparison, and Outcome framework for the review included: (1) adult patients who underwent gynecological surgical procedures; (2) postoperative TAP block as the intervention; (3) comparison with local anesthetic WI; (4) primary outcome: postoperative pain at 1, 4, 12, and 24 hours; secondary outcomes: postoperative opioid consumption, opioid-related side effects, and patient satisfaction. STATA software, version 18 (Stata Corp, College Station, TX, USA), was used for the analysis.

TABULATION, INTEGRATION, AND RESULTS

A total of 213 papers were initially identified. Of these, 10 randomized controlled trials encompassing a total of 604 patients met the inclusion criteria. The meta-analysis studying minimally invasive surgery showed that TAP block was associated with lower pain scores at rest and 1, 4, 12, and 24 hours compared to the WI group. Furthermore, the TAP block resulted in a reduction in opioid consumption at 24 hours, although there was no significant difference in opioid-related adverse effects. Two studies presented data on patient-reported satisfaction, and a pooled analysis was not feasible due to heterogeneity.

CONCLUSION

TAP block seems to provide better postoperative pain control after laparoscopic gynecologic procedures and reduces opioid use compared to WI in gynecologic surgery.

Short- and long-term outcomes of vaginal, laparoscopic, and robotic-assisted surgery in "oldest old" endometrial cancer

OBJECTIVE

To assess the safety and long-term effectiveness of minimally invasive approach in managing "oldest old" endometrial cancer patients.

METHODS

This is a retrospective cohort, multi-institutional study. Consecutive patients, treated between 2000 and 2020, with apparent early-stage endometrial cancer patients, aged ≥85 years. Surgery-related outcomes of robotic-assisted, laparoscopic, and vaginal surgery were compared. Survival was evaluated in patients with at least 3-year follow-up data.

RESULTS

Charts of 82 endometrial cancer patients "oldest old" were retrieved. Intermediate-high and high-risk endometrial cancer patients accounted for 26 (31.7 %) and 17 (20.7 %), respectively. In total, 12 (15 %), 45 (55 %), and 25 (30 %) patients underwent robotic-assisted, laparoscopic, and vaginal surgery, respectively. Looking at surgery-related outcomes, robotic-assisted surgery correlated with a longer operative time (p < 0.001) and longer length of hospital stay (p = 0.002) in comparison to laparoscopic and vaginal approaches. Overall, seven (8.5 %) conversions from the planned approach occurred. The surgical approach did not influence disease-free survival (p = 0.6061) and overall survival (p = 0.4950). Via multivariate analysis, only serosal/adnexal invasion correlated with the risk of death (HR: 3.752, p = 0.038).

CONCLUSIONS

All three minimally invasive approaches are safe and effective methods for managing endometrial cancer in the oldest old population. Chronological age, per se, should not be considered a contraindication for receiving minimally invasive surgery.

Multimodal Prehabilitation for Gynecologic Cancer Surgery

Surgical treatment is commonly employed to treat patients with gynecologic cancer, although surgery itself may function as a stressor, reducing the patients' functional capacity and recovery. Prehabilitation programs attempt to improve patients' overall health and baseline function prior to surgery, thereby enhancing recovery and lowering morbidity. In recent years, prehabilitation has come to primarily refer to multimodal programs that combine physical activity, nutritional support, psychological well-being, and other medical interventions. However, the specific methods of implementing prehabilitation and measuring its effectiveness are heterogeneous. Moreover, high-level evidence regarding prehabilitation in gynecologic cancer surgery is limited. This review provides a summary of multimodal prehabilitation studies in gynecologic oncologic surgery. Enhanced postoperative recovery, lower postoperative complications, lower rate of blood transfusions, and faster gastrointestinal functional recovery have been reported after multimodal prehabilitation interventions. Patients and healthcare professionals should recognize the importance of prehabilitation in the field of gynecologic oncologic treatment, based on the emerging evidence. In addition, there is a need to establish an appropriate target group and construct a well-designed and tailored prehabilitation program.

Predictive Power of the Fried Phenotype in Assessing Postoperative Outcomes in Patients Undergoing Craniotomy for Tumor Resection

BACKGROUND AND OBJECTIVES

Compared with the modified Frailty Index-11 (mFI-11) frailty tool, reflective of patient comorbidities, the Fried phenotype weighs functional patient variables. This study examined using the Fried phenotype in predicting postoperative outcomes in craniotomy for patients with tumor.

METHODS

This retrospective cohort analysis included patients with Current Procedural Terminology codes for supratentorial/infratentorial tumor resections and preoperative frailty scores. Chart review collected the remaining variables for the primary outcome, length of stay (LOS), and secondary outcomes, discharge disposition and postoperative complications. Basic descriptive statistics summarized patient demographics, clinical parameters, and postoperative outcomes. χ 2 tests, t -tests, and ANOVA examined associations and mean differences. Logistic and Poisson regressions explored predictor-outcome relationships.

RESULTS

Over 7 years, these 153 patients underwent Fried assessments. The Fried score was biased toward females being more frail (nonfrail 38.0% female, prefrail 50.0% female and frail 65.6% female, P = .027) but not by age, body mass index, or tumor type. The mFI-11 was biased by age (nonfrail 67.8 years vs frail 72.3 years, P < .001) and body mass index (nonfrail 27.5 vs frail 30.8, P < .001) but not sex or tumor type. The Fried score was significantly correlated with increased LOS's (odds ratio [OR] = 5.92, 95% CI = 1.66-21.13, P < .001) but the mFI-11 was not (OR = 0.82, 95% CI = 0.35-1.93, P = .64). The Fried phenotype was significantly correlated with discharge disposition location ( P = .016), whereas the mFI-11 was not ( P = .749). The Fried score was significantly correlated with postoperative complications (OR = 1.36, 95% CI = 1.08-1.71, P = .01), whereas the mFI-11 was not (OR = 1.10, 95% CI = 0.86-1.41, P = .44).

CONCLUSION

The Fried phenotype more accurately correlates with postoperative outcomes including LOS, discharge disposition location, and complications than does the mFI-11 score. These findings can be used to guide preoperative planning, inform consent, and potentially identify patients who may benefit from functional optimization in the preoperative period to improve postoperative outcomes.

Informed consent in gynecological oncology: a JAGO/NOGGO survey on real-world practices in daily clinical routine

PURPOSE

Informed consent is a quintessential element of contemporary medicine, reflecting the fundamental right of patients to participate in decision-making regarding their health. Despite its critical importance, there is a lack of data on real-world practices regarding patient informed consent in the context of modern, high-pressure medical environments.

METHODS

We conducted a multinational multicentric survey from February 24, 2022, to September 14, 2022, investigating the practices and challenges surrounding informed consent in hospitals across Germany, Austria, and Switzerland with the use of a specifically developed questionnaire.

RESULTS

Drawing on over 200 responses from gynecologists, the survey shows a critical need for structured training in conducting informed consent discussions with over 80% of participants expressing interest in courses addressing this aspect. Notably, a considerable portion of the physicians (59.9%) reported conducting discussions on procedures they had never personally witnessed. Significant disparities between types of hospitals and professional groups were observed in the frequency of informed consent discussions, with limitations arising from factors such as time constraints, language barriers, and insufficient resources for patient education. Moreover, the psychological burden experienced by physicians after informed-consent discussions underscores the need for systemic changes to alleviate concerns regarding patient safety, legal repercussions, and patient satisfaction.

CONCLUSION

This study serves as a call to action, emphasizing the need of enhancing resources and support for medical professionals to uphold the principles of empathic and comprehensive patient information and shared decision-making.

TRIAL REGISTRY

DRKS00028295, 25.07.2024.

Effect of Enhanced Recovery after Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction

BACKGROUND

 Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

METHODS

 A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.

RESULTS

 Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.

CONCLUSION

 ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Implementation of enhanced recovery protocol did not increase rates of acute kidney injury in open gynecologic oncology surgery: A single-institution experience

OBJECTIVE

To compare the incidence of acute kidney injury (AKI) among patients undergoing gynecologic surgery before and after implementing an Enhanced Recovery After Surgery (ERAS) pathway.

METHODS

We conducted a retrospective review of medical records from Mayo Clinic during three time periods when ERAS was used, focusing on patients who underwent open gynecologic surgery. AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria. We used inverse-probability of treatment weighting (IPTW) to adjust for baseline covariates between pre-ERAS (135 patients) and post-ERAS (486 patients) cohorts. Statistical comparisons were made using t-test, Wilcoxon rank-sum, chi-square or Fisher's exact test, and univariate logistic regression with odds ratio (OR) and 95 % confidence interval (CI).

RESULTS

Pre-IPTW, the AKI incidence was similar between cohorts (10.4 % vs 8.4 %, p = 0.48), and the odds of AKI for post-ERAS patients compared to pre-ERAS was not significant (OR 0.80, 95 % CI 0.42-1.51). After IPTW-adjustment, the AKI incidence remained comparable (10.3 % vs 8.1 %, p = 0.41), with the odds ratio unchanged (OR 0.76, 95 % CI 0.40-1.45). AKI patients were older (mean 67.0 vs 62.4 years, p < 0.01), had higher ASA scores (61.8 % vs 45.2 %, p = 0.02), lower preoperative hemoglobin (median 10.8 vs 12.5 g/dL, p < 0.01), longer surgeries (median 331 vs 222 min, p < 0.01), greater intraoperative blood loss (median 800 vs 500 mL, p < 0.01), more transfusions (56.4 % vs 29.3 %, p < 0.01), and higher fluid volumes (median 5750 vs 4165 mL, p < 0.01).

CONCLUSION

The ERAS pathway did not significantly impact AKI incidence in gynecologic surgery patients. AKI remains associated with increased postoperative complications, highlighting the need for improved risk prediction and preventive strategies.

Optimizing prehabilitation in gynecologic malignancies: Improving acceptance, overcoming barriers, and managing program complexity

Prehabilitation aims to improve patients' physical condition before a stressful event, such as surgery, and enhance recovery. Despite its potential benefits, many emerging prehabilitation programs face challenges in enrolling or retaining patients. In our prehabilitation study PHOCUS, which aims to prepare ovarian cancer patients for surgery, we have also encountered lower acceptance and retention rates. Particularly the most vulnerable patients, who are old and frail, and may benefit the most from the prehabilitation, decline participation due to the complexity of the proposed program. In our review we discussed obstacles and barriers that prevent patients' participation based on both literature and our experience. Among the main reasons are patient's low motivation, high intensity of the program and a lack of social support. To overcome these challenges, we suggest increasing the program's flexibility, adapting the program according to individual patient's needs and enhancing patients' education about the benefits of prehabilitation.

A review of enhanced recovery after surgery concept in perioperative radical prostatectomy for prostate cancer

Radical prostatectomy (RP) is the main treatment for early-stage localized prostate cancer. With the improvement of medical technology, radical prostatectomy is mainly performed under laparoscopy or robot assistance. With the continuous deepening of the Enhanced Recovery After Surgery (ERAS) concept in clinical practice, patients have increasingly high requirements for postoperative recovery. The ERAS concept is of great significance in the perioperative period and has been used in many surgical fields due to its ability to improve prognosis. ERAS has not yet been widely applied in urology and the research progress of other disciplines in ERAS has promoted its development in radical prostatectomy. This review summarizes the key elements of ERAS in the perioperative period of RP, aiming to demonstrate the superiority of ERAS and provide new references and inspirations for urologists.

Urgent focus on enhanced recovery after surgery of AIDS patients with limb fractures

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Methods

A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively.

Results

Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group.

Conclusion

The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE: 2

Frailty in middle-aged and older adult postoperative patients with gynecological malignancies structural equation modeling

Background

Frailty and self-management are important determinants of quality of life in cancer patients. However, their synergistic effects and potential mechanisms on quality of life in middle-aged and older adult postoperative gynecologic malignancy patients have not been adequately studied.

Objective

This cross-sectional study aimed to explore the relationship between frailty, self-management, and quality of life in middle-aged and older adult postoperative gynecologic malignancy patients.

Methods

A cross-sectional study was conducted from January 2024 to April 2024 in three gynecological wards of a tertiary hospital in Wuxi. The study recruited 177 patients aged 45 years or older who underwent surgery for gynecologic malignancies (cervical, ovarian, and endometrial cancer). Data were collected using demographic and clinical characteristics, the Edmonton Frailty Scale, the Self-Management Competence Scale, and the EORTC Core Quality of Life Questionnaire. Structural equation modeling was used to explore the interactions between frailty, self-management, and quality of life.

Results

The prevalence of frailty in middle-aged and older adult postoperative gynecologic malignancy patients was 39.5%, with a mean total self-management score of 125.81 ± 13.21 and a mean total quality of life score of 69.26 ± 10.88. The fit indices of the model indicated a good fit, and that frailty had multiple effects on quality of life; specifically, frailty could affect the quality of life directly or through self-management, i.e., self-management partially mediated frailty and quality of life.

Conclusion

Self-management is a mediating variable between frailty and quality of life, suggesting that clinical workers can intervene in self-management skills to improve patient's quality of life and physical and mental health.

Can a Continuous Wound Infiltration System Replace Intravenous Patient-Controlled Analgesia for Postoperative Pain Management after a Single-Port Access Laparoscopy?

Background: The aim of this study was to determine whether continuous wound infiltration (CWI) can replace intravenous patient-controlled analgesia (IV PCA) and to investigate effective pain control strategies after a single-port access (SPA) laparoscopy for adnexal disease. Methods: A total of 470 patients (the CWI group [n = 109], the IV PCA group [n = 198], and the combined group [n = 163]) who underwent an SPA adnexal laparoscopy and who received CWI or IV PCA for postoperative pain management were retrospectively reviewed. The numeric rating scale (NRS) pain score at 6, 12, 24, and 48 h (h) after surgery and the total amount of fentanyl administered via IV PCA were collected. The incidence of postoperative nausea and vomiting (PONV) and the total amount of rescue antiemetic drugs administered were also evaluated. Results: The mean NRS pain scores at 6 h (combined vs. PCA vs. CWI, 3.08 vs. 3.44 vs. 3.96, p < 0.001), 12 h (2.10 vs. 2.65 vs. 2.82, p < 0.001), and 24 h (1.71 vs. 2.01 vs. 2.12, p < 0.001) after surgery were significantly lower in the combined group. CWI showed a similar pain-reduction effect after surgery compared to IV PCA, except for the acute phase (within 6 h after surgery). The incidence of PONV during the entire hospitalization period was significantly lower in the CWI group compared to the groups using IV PCA (p < 0.05). The combined group had a significantly lower incidence of PONV and use of rescue antiemetics than the IV PCA group (p < 0.05). The combined group required significantly less total PCA fentanyl compared to the IV PCA group (combined vs. PCA, 622.1 μg vs. 703.1 μg, p < 0.001). Conclusions: CWI is an effective alternative to IV PCA and has fewer side effects. Combined use of CWI and IV PCA may be an ideal pain management strategy, offering a strong pain-reduction effect and only moderate side effects.

Interaction mechanism of discharge readiness between discharge teaching and post-discharge outcomes in gynecological inpatients: a mediation analysis

BACKGROUND

With the rapid implementation of enhanced recovery after surgery, most gynecological patients are discharged without full recovery. Discharge planning is necessary for patients and their families to transition from hospital to home. Discharge teaching and discharge readiness are two core indicators used to evaluate the quality of discharge planning, which impacts the post-discharge outcomes. To improve post-discharge outcomes, the interaction mechanism of the three variables needs to be determined, but few studies have focused on it.

OBJECTIVES

Explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes of gynecological inpatients.

METHODS

Discharge teaching and discharge readiness were measured by the Quality of Discharge Teaching Scale (QDTS) and Readiness for Hospital Discharge Scale (RHDS). Post-discharge outcomes on postoperative Day 7 (POF-D7) and postoperative Day 28 (POF-D28) were measured by a self-designed tool. Spearman correlations, Kruskal‒Wallis tests and Mann‒Whitney U tests were conducted to explore the correlation between post-discharge outcomes and other variables. Mediation analysis was used to explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes.

RESULTS

QDTS and RHDS showed strong positive correlations with post-discharge outcomes. The mediation analyses verified that RHDS was a full mediator between QDTS and POF-D7, and the indirect effect accounted for 95.6% of the total direct effect. RHDS was a partial mediator between QDTS and POF-D28, and the indirect effect accounted for 50.0% of the total direct effect. RHDS was a full mediator between QDTS and total scores of post-discharge outcomes, and the indirect effect accounted for 88.9% of the total direct effect.

CONCLUSIONS

Discharge teaching can improve the post-discharge outcomes of gynecological inpatients through the intermediary role of discharge readiness. Doctors and nurses should value the quality of discharge teaching and the discharge readiness improving of gynecological inpatients. Future studies should note the interaction mechanism of the three variables to explore more efficient ways of improving post-discharge outcomes of gynecological inpatients.

A retrospective cohort study on enhanced recovery after surgery (ERAS) in patients with diabetic foot ulcer

Enhanced recovery after surgery (ERAS) has been successfully integrated into a diverse array of surgical fields to improve the quality and efficacy of treatment intervention. Nonetheless, the application of the ERAS protocol for patients with diabetic foot ulcer (DFU) subsequent to undergoing surgical procedures has not been previously explored. Therefore, this study aimed to investigate the effect of an enhanced recovery protocol on perioperative outcomes in patients with DFU following surgical procedures. A retrospective analysis was conducted on 112 patients with DFU who underwent surgery between January 2020 and December 2021 at a tertiary referral care center. In total, 57 patients received standard perioperative care (the non-ERAS group), and 55 patients received ERAS care (the ERAS group). The primary outcomes included the length of stay (LOS), wound healing time, patient satisfaction, and costs, serving as the basis for assessing the effectiveness of the two approaches. Secondary outcomes included preoperative anxiety (APAIS score), nutritional status (PG-SGA), pain (NRS score), the incidence of lower-extremity deep vein thrombosis (DVT), the reduction in lower-limb circumference, and the activity of daily living scale (Barthel Index). The ERAS group exhibited significantly shorter LOS (11.36 vs. 26.74 days; P < 0.001) and lower hospital costs (CNY 62,165.27 vs. CNY 118,326.84; P < 0.001), as well as a higher patient satisfaction score and Barthel Index score (P < 0.05). Additionally, we found a lower APAIS score, incidence of DVT, and circumference reduction in lower limbs in the ERAS group compared to the non-ERAS group (P < 0.05). In comparison, the wound healing time, nutritional status, and pain levels of participants in both groups showed no significant difference (P > 0.05). By reducing the LOS and hospital costs, and by minimizing perioperative complications, the ERAS protocol improves the quality and efficacy of treatment intervention in patients with DFU who underwent surgical procedures.Trial registration number: ChiCTR 2200064223 (Registration Date: 30/09/2022).

Prehabilitation Consultation on Self-Care and Physical Exercise in Patients Diagnosed with Abdominopelvic Cancer: Protocol of the Study

BACKGROUND

Introduction: Prehabilitation in the field of oncology has been defined as "the process in the continuum of care that occurs between diagnosis and the start of treatment involving physical and psychological measures that determine the patient's baseline functional status."

AIM

To determine the effectiveness of a Prehabilitation consultation on self-care and targeted physical exercise for patients diagnosed with abdominopelvic cancer.

DESIGN

An observational study that will evaluate the pre-post efficacy of an ad-hoc designed Prehabilitation intervention. The study population consists of patients diagnosed with colon or gynecological cancer with a surgical indication as part of their therapeutic plan from the General Surgery Services. It is configured around four key interventions: (a) health education and self-care, (b) specific nutritional counseling, (c) initial psychological assessment, and (d) directed physical exercise intervention. Health education, self-care interventions, and physical exercise will be carried out weekly from diagnosis to the scheduled surgery day.

RESULTS

Aspects such as self-care capacity or agency, perioperative anxiety, aerobic capacity, strength and flexibility, postoperative complications, and recovery time to adjuvant treatment will be measured using tools such as Appraisal of self-care agency scale (ASA), State Trait Anxiety Inventory (STAI), walking test, sit and Reach, Hand Grip or Squad Jump.

CONCLUSION

Utilizing validated tools for analyzing selected variables will contribute to refining and expanding care guidelines, ultimately enhancing support for both patients and their caregivers.

The impact of enhanced recovery after surgery (ERAS) on opioid consumption and postoperative pain levels in elective spine surgery

OBJECTIVE

Enhanced Recovery after Surgery (ERAS) protocols were developed to counteract the adverse effects of the surgical stress response, aiming for quicker postoperative recovery. Initially applied in abdominal surgeries, ERAS principles have extended to orthopedic spine surgery, but research in this area is still in its infancy. The current study investigated the impact of ERAS on postoperative pain and opioid consumption in elective spine surgeries.

METHODS

A single-center retrospective study of patients undergoing elective spine surgery from May 2019 to July 2020. Patients were categorized into two groups: those enrolled in the ERAS pathway and those adhering to traditional surgical protocols. Data on demographics, comorbidities, length of stay (LOS), surgical procedures, and postoperative outcomes were collected. Postoperative pain was evaluated using the Numerical Rating Scale (NRS), while opioid utilization was quantified in morphine milligram equivalents (MME). NRS and MME were averaged for each patient across all days under observation. Differences in outcomes between groups (ERAS vs. treatment as usual) were tested using the Wilcoxon rank sum test for continuous variables and Pearson's or Fisher's exact tests for categorical variables.

RESULTS

The median of patient's mean daily NRS scores for postoperative pain were not statistically significantly different between groups (median = 5.55 (ERAS) and 5.28 (non-ERAS), p=.2). Additionally, the median of patients' mean daily levels of MME were similar between groups (median = 17.24 (ERAS) and 16.44 (non-ERAS), p=.3) ERAS patients experienced notably shorter LOS (median=2 days) than their non-ERAS counterparts (median=3 days, p=.001). The effect of ERAS was moderated by whether the patient had ACDF surgery. ERAS (vs. non-ERAS) patients who had ACDF surgery had 1.64 lower average NRS (p=.006). ERAS (vs. non-ERAS) patients who had a different surgery had 0.72 higher average NRS (p=.02) but had almost half the length of stay, on average (p<.001).

CONCLUSIONS

The current study underscores the dynamic nature of ERAS protocols within the realm of spine surgery. While ERAS demonstrates advantages such as reduced LOS and improved patient-reported outcomes, it requires careful implementation and customization to address the specific demands of each surgical discipline. The potential to expedite recovery, optimize resource utilization, and enhance patient satisfaction cannot be overstated. However, the fine balance between achieving these benefits and ensuring comprehensive patient care, especially in the context of postoperative pain management, must be maintained. As ERAS continues to evolve and find its place in diverse surgical domains, it is crucial for healthcare providers to remain attentive to patient needs, adapting ERAS protocols to suit individual patient populations and surgical contexts.

Effects of Ward Night Noise Management in the Context of Enhanced Recovery After Surgery on Postoperative Sleep Quality, Anxiety, and Hormone Levels of Thoracic Surgery Patients with Lung Cancer

OBJECTIVE

This study aimed to analyze the effects of ward night noise management in the context of enhanced recovery after surgery (ERAS) on postoperative sleep quality and anxiety of thoracic surgery patients with lung cancer.

METHODS

This retrospective analysis included 118 patients with lung cancer who underwent thoracic surgery (from January 2020 to December 2021). The patients were categorized into the control and observation groups, which comprised 63 and 55 cases, respectively, on the basis of perioperative management plans. The two groups were compared in terms of their score in Athens Insomnia Scale (AIS), the State-Trait Anxiety Inventory (STAI) and Self-Rating Depression Scale (SDS), salivary cortisol (SC), thyroid hormone (TSH), and angiotensin II (Ang II) levels, and noise measurements at various timepoints.

RESULTS

The observation group exhibited a significantly lower noise level than the control group (P < 0.001). No statistically significant difference was found in the AIS, STAI, and SDS scores and Ang II, TSH and SC levels between the two groups before their surgery (P > 0.05). Compared with the control group, the observation group achieved significantly lower AIS scores at 1, 3 and 7 days after surgery (P < 0.05) and significantly lower STAI scores at 1 and 3 days postsurgery (P < 0.05). Significantly lower Ang II, TSH and SC indices were observed in the observation group after management than the control group (P < 0.05).

CONCLUSION

Night noise management in the context of ERAS can improve sleep quality and adverse moods of patients who underwent thoracic surgery for lung cancer, which helps in the promotion of prognosis.

Impacts of enhanced recovery after surgery nursing interventions on wound infection and complications following bladder cancer surgery: A meta-analysis

A meta-analysis was executed to comprehensively examine the impacts of enhanced recovery after surgery (ERAS) care interventions on complications and wound infections following bladder cancer (BCa) surgery. Computer searches were carried out in Embase, Google Scholar, Cochrane Library, PubMed, Wanfang and CNKI, from their inception to November 2023, for RCTs regarding perioperative ERAS nursing interventions in patients with BCa. Two independent researchers performed literature screening, extracted data and carried out quality evaluations. Stata 17.0 software was utilized for the analysis of the data. Ultimately, 16 RCTs, involving 1190 patients, were included. The analysis showed that, in comparison with conventional nursing methods, perioperative ERAS nursing application in patients with BCa remarkably decreased the occurrence of wound infections (OR: 0.31, 95% CI: 0.16-0.59) and complications (OR: 0.19, 95% CI: 0.13-0.28). Our study indicates that perioperative care based on the ERAS concept remarkably decreased the occurrence of wound infections and complications following BCa surgery, demonstrating notable nursing efficacy and meriting widespread clinical promotion.

Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery

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.

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

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

Protocol for the PORT study: short-term perioperative rehabilitation to improve outcomes in cardiac valvular surgery - a randomised control trial

INTRODUCTION

Perioperative rehabilitation (PORT) has shown a positive effect on patients undergoing cardiac surgery. However, there are minimal data on the impact of short-term PORT in cardiac surgery, which is associated with higher postoperative morbidity and mortality. The trial will assess the efficacy of short-term PORT in reducing in-hospital mortality, postoperative pulmonary complications and length of stay, compared with the usual care in cardiac surgical patients.

METHODS AND ANALYSIS

This is a single-centre prospective, randomised, open, controlled trial with a 1:1 ratio. Consecutive 800 adult patients undergoing elective valve surgery will be randomised to either usual care or in-hospital short-term PORT that consists of education, inspiratory muscle training, active cycle of breathing techniques and early mobilisation. The primary outcome of this study will be a composite of in-hospital all-cause mortality, incidence of postoperative pulmonary complications and the ratio of postoperative hospitalisation >7 days.

ETHICS AND DISSEMINATION

The PORT study was granted by the Medical Research Ethics Committee of Guangdong Provincial People's Hospital in August 2018. Findings will be disseminated to patients, clinicians and commissioning groups through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT03709511.

Development of and adherence to an ERAS® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study

BACKGROUND AND OBJECTIVE

There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery.

METHODS

Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire.

RESULTS

The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups.

CONCLUSION

The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.

The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section

OBJECTIVE

To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS).

METHODS

This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups.

RESULTS

A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay.

CONCLUSIONS

Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.

Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis

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.

Early oral diet may enhance recovery from benign gynecologic surgery: A single center prospective study

BACKGROUND

Early dietary intake enhanced recovery after surgery (ERAS). There remains a gap in the recognition and implementation of early diet after surgery in medical institutions in Taiwan. This study aimed to investigate whether early oral intake after benign gynecologic surgery results in favorable outcomes in Taiwanese patients.

METHODS

This was a prospective controlled nonrandomized cohort study. Patients who underwent benign gynecological surgery were included in the early- and conventional-diet groups. The primary outcome was length of hospital stay, and the secondary outcome was postoperative complications.

RESULTS

Forty and 38 patients were included in the early and conventional-diet groups, respectively. The early-diet group demonstrated significantly reduced length of hospital stay (the early-diet group, 2.58 ± 0.93 days; conventional-diet group, 4.16 ± 1.13 days; p < 0.001). No increase in postoperative complications was observed in the early-diet group. Laparoscopic surgery reduced the length of hospital stay (β, -0.65; 95% confidence interval [CI], -1.22 to -0.08; p = 0.027), while an increased length of hospital stay was associated with higher visual analog scales (VAS, β, 0.21; 95% CI, 0.03-0.39; p = 0.026) and the conventional-diet group (β, 1.13; 95% CI, 0.65-1.61; p < 0.001) as assessed by multivariate regression analysis.

CONCLUSION

Patients who underwent benign gynecologic surgery tolerated an early oral diet well without an increase in complications. Laparoscopic surgery and lower pain scores also enhanced postoperative recovery.

Enhanced recovery nursing and mental health education on postoperative recovery and mental health of laparoscopic liver resection

BACKGROUND

Patients undergoing laparoscopic resection of liver metastases of colorectal cancer are prone to negative emotions and decrease of digestive function. Early nursing and psychological intervention are necessary.

AIM

To observe the effect of enhanced recovery nursing combined with mental health education on postoperative recovery and mental health of patients undergoing laparoscopic resection of liver metastases of colorectal cancer.

METHODS

One hundred and twenty patients who underwent laparoscopic resection of liver metastases of colorectal cancer at our hospital between March 2021 and March 2023, were selected as participants. The patients admitted from March 1, 2021 to February 28, 2022 were set as the control group, and they were given routine nursing combined with mental health education intervention. While the patients admitted from March 1, 2022 to March 31, 2023 were set as the observation group, they were given accelerated rehabilitation surgical nursing combined with mental health education intervention. The differences in postoperative recovery-related indices, complications and pain degrees, and mental health-related scores were compared between groups. The T lymphocyte subset levels of the two groups were also compared.

RESULTS

The postoperative exhaust, defecation, eating and drainage time of the observation group were shorter than those of the control group. The pain scores of the observation group were lower than those of the control group at 6, 12, 24, 48, and 72 h after surgery. The cumulative complication rate of the observation group was lower than that of the control group (P < 0.05). The CD4+/CD8+ in the observation group was higher than that in the control group 3 d after surgery (P < 0.05). After intervention, the self-rating depression scale, self-rating anxiety scale, avoidance dimension, and yielding dimension in Medical coping style (MCMQ) scores of the two groups were lower than those prior to intervention, and the scores in the observation group were lower than those in the control group (P < 0.05). The face dimension score in the MCMQ score was higher than that before intervention, and that of the observation group was higher than that of the control group (P < 0.05). After intervention, the total scores of the life function index scale (FLIC) and psychological well-being scores of cancer patients in the two groups, and the physical and social well-being scores in the observation group, were higher than those before intervention. The nursing satisfaction of the observation group was higher than that of the control group (P < 0.05). The physical, psychological, and social well-being, and the total FLIC scores of the observation group were higher than those in the control group after surgery (P < 0.05).

CONCLUSION

Enhanced recovery nursing combined with mental health education can promote the recovery of gastrointestinal function, improve the mental health and quality of life of patients after laparoscopic resection of colorectal cancer liver metastases, and reduce the incidence of complications.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

OBJECTIVES

Race and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race.

METHODS

A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race.

RESULTS

Of 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery.

CONCLUSIONS

Fewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

De novo myeloid sarcoma mimicking gynecological tumors: a retrospective case series of eight patients

OBJECTIVE

To describe myeloid sarcoma (MS) that mimic gynecological tumors and provide guidelines for improving the diagnosis and treatment of patients.

METHODS

This case series study retrospectively analyzed the clinicopathological characteristics and oncological outcomes of female patients who were histologically diagnosed with MS after initially presenting with reproductive-system tumors at the Peking Union Medical College Hospital between January 2000 and March 2022.

RESULTS

There were eight cases in which MS mimicked cervical cancer, ovarian cancer, or hysteromyoma. Six patients had isolated MS, and the other two had acute myeloid leukemia (AML)-M2. The average age was 39.00 ± 14.26. They each sought advice from a gynecological oncologist at the initial visit, complaining of irregular bleeding (3/8), low abdominal pain (3/8), dysmenorrhea (1/8), or an accidentally found mass (1/8). CT/MRI exams revealed that the average tumor size reached 5.65 ± 2.35 cm, with 50% of the tumors being larger than 8 cm. The final diagnoses were confirmed by biopsy (2/8) or postoperative pathology (6/8); the most frequent positive immunohistochemical markers were Ki-67 (60-90%), MPO (100%), LCA (62.5%), CD43 (62.5%), CD117 (62.5%), CD99 (50%), vimentin (37.5%), and lysozyme (25%). MLL/AF9 gene fusions and CEBPA, JAK2, NRAS, and FLT3-TKD mutations were found in the patients. Six (75%) of the patients showed a complete response after upfront treatment using chemotherapy + surgery and experienced no recurrence during follow-up. The overall survival (OS) rate was 72.9%, and the 5-year OS rate was 72.9% (95%CI: 0.4056-1.000). The median OS was 26 months (range: 3-82).

CONCLUSION

For patients with isolated MS, treatment by chemotherapy and surgery are radical procedure, and initial treatment using chemotherapy alone should be considered for MS with synchronous intramedullary AML. Poor response to chemotherapy, short interval to leukemia occurrence, and heavy tumor burden (> 10 cm) could indicate a poor prognosis for patients with MS.

Application of enhanced recovery after surgery in perioperative patients undergoing laparoscopic surgery for gastric cancer: A meta-analysis

BACKGROUND

To analyze the effect of enhanced recovery after surgery (ERAS) in perioperative patients undergoing laparoscopic surgery for gastric cancer (GC).

METHODS

We searched the literature databases of PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://www.webofscience.com/) for studies related to ERAS and laparoscopic surgery for GC from their inception till October 2022, and the retrieved articles were further screened for analysis. The literature quality was evaluated based on the Cochrane risk of bias tool. The endpoints included the first postoperative exhaust time, first postoperative bowel movement, length of stay, complications and hospitalization expenses. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

11 studies were included, involving 2039 patients. Meta-analysis showed that the first postoperative exhaust and bowel movement were earlier and the length of stay was shorter in the experimental group (e.g.,) than in the control group (CG) (P < .05). Moreover, a lower incidence of complications and markedly reduced hospitalization expenses were determined in for example (P < .05). Due to the heterogeneity in the comparison of indicators such as the first postoperative exhaust and bowel movement across articles, a funnel plot was drawn for observations. The plot was found to be basically symmetrical, indicating small results bias and reliable reference significance of our findings.

CONCLUSION

ERAS for perioperative patients undergoing laparoscopic surgery for GC can effectively shorten the postoperative rehabilitation cycle of patients, improve surgical safety and reduce treatment costs.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy

INTRODUCTION

Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse.

METHODS

This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS.

RESULTS

A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different.

CONCLUSION

Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Feasibility research of enhanced recovery after surgery implemented in esophageal cancer patients who underwent neoadjuvant chemotherapy

Background

Enhanced recovery after surgery (ERAS) is a perioperative management protocol to accelerate patient recovery. This study aimed to evaluate the feasibility of ERAS protocols implemented in patients who underwent neoadjuvant chemotherapy (NACT) before minimally invasive McKeown esophagectomy.

Methods

This retrospective study compared the short-term clinical outcomes in esophagectomy patients from June 2018 to June 2021. Subjects were divided into two categories: those who underwent NACT (NACT group) and the non-NACT group.

Results

There was no significant difference in total postoperative complication morbidity between the NACT and non-NACT groups (21.2% vs. 20.7%, P=0.936). In addition, the hospital length of stay post-surgery (7.90 vs. 7.71 days, P=0.424) was not significantly longer when compared to the non-NACT group. The time to chest tube removal (5.37 vs. 5.13 days, P=0.238) and first bowel movement (2.92 vs. 3.01 days, P=0.560) was also similar between the two groups.

Conclusions

There was no significant difference in postoperative complications rate, postoperative hospital length of stay, and readmission rate between the two group. This study proved that ERAS protocols seemed to be safe and feasible for patients who received NACT before esophagectomy.

ERAS implementation in an urban patient population undergoing gynecologic surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols improve outcomes. We investigated ERAS implementation in a population with comorbid conditions, inadequate insurance, and barriers to healthcare undergoing gynecologic surgery.

OBJECTIVE

To investigate ERAS implementation in publicly insured/uninsured patients undergoing gynecologic surgery on hospital length of stay (LOS), 30-day hospital readmission rates, opioid administration, and pain scores.

STUDY DESIGN

Data were obtained pre- and post-ERAS implementation. Patients undergoing gynecologic surgery with private insurance, public insurance, and uninsured were included (N = 589). LOS, readmission <30 days, opioid administration, and pain scores were assessed.

RESULTS

Implementation of ERAS led to shorter LOS 1.75 vs. 1.49 days (p = 0.008). Average pain scores decreased from 3.07 pre-ERAS vs. 2.47 post-ERAS (p = <0.001). Opioid use decreased for ERAS patients (67.22 vs. 33.18, p = <0.001). Hospital readmission rates were unchanged from 8.2% pre-ERAS vs. 10.3% post-ERAS (p = 0.392).

CONCLUSIONS

ERAS decreased pain scores and opioid use without increasing LOS or readmissions.

Knowledge, attitude and application towards fast track surgery among operating room paramedics: a cross-sectional study

BACKGROUND

Fast track surgery has shown its effectiveness to accelerate recovery and gained acceptance in many operations. However, data for paramedics using fast track surgery are limited in China. The aims of our study are to evaluate the knowledge, attitude and application status of fast track surgery in paramedics and to provide suggestions for the better application of fast track surgery.

METHODS

Two Hundred Ninety-one operating room paramedics were investigated by simple random sampling from October 20 to December 20, 2019 time. A self-reported questionnaire was used to collect data with five dimensions: demographic data, cognitive level, knowledge, attitude and application of fast track surgery. Data were analyzed using qualitative and quantitative methods.

RESULTS

19.93% of participants never heard fast track surgery and only 3.32% of participants were very familiar with it. Gender (0.702, 95% CI 0.109-1.294), technical title (0.342, 95% CI 0.126-0.558) and awareness of the concept of fast track surgery (0.471, 95% CI 0.165-0.776) had a correlation with the knowledge level of paramedics towards fast track surgery. In terms of attitude towards fast track surgery, gender (- 1.944, 95% CI -3.830- -0.058), age (0.303, 95% CI 0.021-0.585) and knowledge score of fast track surgery (0.426, 95% CI 0.014-0.838) are related. Half of the paramedics believe the most difficult problem in the application of fast track surgery was the lack of multi-team communication and cooperation.

CONCLUSION

The knowledge of fast track surgery among paramedics in Wuhan is poor, and some paramedics have a negative attitude towards it. As the attitude is positively correlated with the knowledge, it is necessary to improve the knowledge level of fast track surgery among paramedics in Wuhan.

Role of reactive thrombocytosis after primary cytoreductive surgery in advanced ovarian cancer

We investigated the incidence of reactive thrombocytosis after maximal cytoreductive surgery in advanced epithelial ovarian cancer (EOC) and its role in patient survival. We retrospectively reviewed the electronic medical records of patients who underwent primary cytoreductive surgery for advanced EOC from 1 January 2012 to 31 December 2017. We analyzed the serum platelet counts at various time points from before surgery, during the peri-operative period, and after each cycle of adjuvant chemotherapy. A total of 474 patients were eligible for the analysis. Among them, 401 patients (84.6%) had FIGO stage III disease status. The most common histology type was serous adenocarcinoma (405 patients, 85.4%). Seventy-nine patients (22.6%) received splenectomy, and optimal cytoreduction was achieved in 326 patients (68.8%). A week after surgery, thrombocytosis was observed in 165 patients (34.8%) in the entire cohort. Higher platelet counts were observed in patients with splenectomy compared with patients without splenectomy. In particular, thrombocytosis on the fifth cycle of adjuvant chemotherapy showed the most significant effects on overall survival in multivariate analysis. In a logistic regression model, splenectomy was significantly attributed to thrombocytosis on the fifth cycle of chemotherapy. Reactive thrombocytosis after primary cytoreductive surgery is associated with poor survival in advanced EOC, particularly when thrombocytosis is observed during adjuvant chemotherapy.

Can the Full-Percutaneous Endoscopic Lumbar Discectomy in Day Surgery Mode Achieve Better Outcomes Following Enhanced Recovery after Surgery Protocol? A Retrospective Comparative Study

Background

Full-percutaneous endoscopic lumbar discectomy (F-PELD) is a popular operation for the treatment of lumbar disc herniation (LDH). Some studies have reported that F-PELD in day surgery mode produced favorable outcomes for LDH. At the same time, minimally invasive spinal surgery following enhanced recovery after surgery (ERAS) presents a rising trend in recent years, but few studies reported whether F-PELD will produce better outcomes in the day surgery (DS) mode combined with ERAS.

Objective

To analyze whether F-PELD in day surgery mode following ERAS can produce better clinical outcomes than in traditional surgery mode.

Methods

The patients who underwent F-PELD between January 2019 and October 2020 were retrospectively analyzed, and the patients who met the inclusive criteria were followed up. The patients were divided into day surgery (DS) group (n = 152) that combined with ERAS and traditional surgery (TS) group (n = 123) without ERAS. The length of hospital stays (LOS), visual analogue scale (VAS), and Oswestry Disability Index (ODI) of two groups were compared before surgery, immediately after surgery, one month after surgery, and one year after surgery.

Results

A total of 298 patients who underwent F-PELD were reviewed. 290 patients were included in the study and followed up, and 275 patients who had completed the follow-up were available for analysis. There were no statistically significant differences between the two groups in terms of age, gender, preoperative VAS, and ODI. There were significant statistical differences in the VAS and ODI immediately after surgery (VAS for back pain: DS group 1.4 ± 1.1, TS group 2.0 ± 1.2, p &lt; 0.001; VAS for leg pain: DS group 0.8 ± 0.8, TS group 1.1 ± 1.1, p = 0.010; ODI: DS group 5.8 ± 4.3, TS group 7.6 ± 7.4, p = 0.010) and one month after surgery (VAS for back pain: DS group 0.8 ± 0.9, TS group 1.1 ± 1.0, p = 0.035; ODI: DS group 3.2 ± 3.5, TS group 4.5 ± 6.5, p = 0.036). At one year after surgery, the VAS (back pain: DS group 0.3 ± 0.6, TS group 0.3 ± 0.7, p = 0.798; leg pain: DS group 0.2 ± 0.4, TS group 0.1 ± 0.4, p = 0.485) and ODI (DS group 0.8 ± 1.2, TS group 0.7 ± 1.7, p = 0.729) were further improved, but no statistically significant difference was observed between two groups. LOS of DS group (1.38 ± 0.49 days) was significantly shorter than the TS group (5.83 ± 2.24 days, p &lt; 0.001), and some postoperative complications occurred in the TS group, including throat discomfort (n = 5, 4.1%), discomfort after catheterization (n = 7, 5.7%), abdominal distention (n = 3, 2.4%), and nausea (n = 5, 4.1%). None of the above complications resulted in serious consequences.

Conclusion

The F-PELD in day surgery mode following ERAS produced a better short-term clinical effect and reduced the LOS, which is worthy of promotion.

A nomogram to predict prolonged postoperative ileus after intestinal resection for Crohn's disease

PURPOSE

We aim to identify the risk factors of PPOI in patients with CD and create a nomogram for prediction of PPOI for CD.

METHODS

Data on 462 patients who underwent partial intestinal resection for CD in Jin-ling Hospital between January 2019 and June 2021 were retrospectively collected. Univariate and multivariate analyses were performed to determine the risk factors for PPOI and we used the risk factors to create a nomogram. Then we used the Bootstrap-Concordance index and calibration diagrams to evaluate the performance of the Nomogram. Decision curve analysis was performed to evaluate clinical practicability of the model.

RESULTS

The incidence of PPOI was 27.7% (n of N). Course of CD ≥ 10 years, operation time ≥ 154 min, the lowest mean arterial pressure ≤ 76.2 mmHg, in-out balance per body weight ≥ 22.90 ml/kg, post-op day 1 infusion ≥ 2847 ml, post-op lowest K⁺  ≤ 3.75 mmol/L, and post-op day 1 procalcitonin ≥ 2.445 ng/ml were identified as the independent risk factors of PPOI in patients with CD. The nomogram we created by these risk factors presented with good discriminative ability (concordance index 0.723) and was moderately calibrated (bootstrapped concordance index 0.704). The results of decision curve analysis showed that the nomogram was clinically effective within probability thresholds in the 8 to 66% range.

CONCLUSION

The nomogram we developed is helpful to evaluate the risk of developing PPOI after partial intestinal resection for CD. Clinicians can take more necessary measures to prevent PPOI in CD's patients or at least minimize the incidence.

Enhanced recovery after surgery improves short-term outcomes in patients undergoing esophagectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is a perioperative management protocol that aims to accelerate patient recovery. This study aimed to evaluate its benefits in patients with resectable esophageal cancer.

METHODS

This retrospective study compared patients before (January 2013 to December 2016) and after (June 2018 to December 2020) ERAS protocol implementation in our hospital. A propensity score-matched (PSM) analysis was used to compare short-term surgical outcomes between ERAS and non-ERAS groups. After PSM, each group included 243 patients.

RESULTS

There were significant differences in hospital length of stay after surgery (7.40 vs. 11.17 days, P<.001) and hospitalization cost (¥69380 vs. ¥78075, P<.001) between the ERAS and non-ERAS groups. The time to chest tube removal (4.91 vs. 7.16 days, P<.001) and first bowel movement (2.87 vs. 3.97 days, P<.001) was significantly shorter in the ERAS group. However, there was no significant difference in total postoperative complication morbidity (20.2% vs. 25.1%, P=0.193). The complication of postoperative atelectasis or pneumonia was significantly lower in the ERAS group (P=0.003), but there was no significant difference in occurrence of ≥Grade III complications between the two groups (12.3% vs. 11.5%, P=0.889).

CONCLUSIONS

We demonstrated that ERAS could reduce the hospital stay, numerical pain scores, and hospitalization costs without increasing postoperative complication and readmission. Furthermore, subgroup analyses revealed that ERAS was safe for older people (>70 years old).