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Lin X, Feng X, Sun L, Wang Y, Wu X, Lu S, Shao L, Wang W, Yang L, Geng W, Lin H. Effects of esketamine on postoperative fatigue syndrome in patients after laparoscopic resection of gastric carcinoma: a randomized controlled trial. BMC Anesthesiol 2024; 24:185. [PMID: 38789968 PMCID: PMC11127346 DOI: 10.1186/s12871-024-02513-w] [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: 10/31/2023] [Accepted: 03/27/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Despite the implementation of various postoperative management strategies, the prevalence of postoperative fatigue syndrome (POFS) remains considerable among individuals undergoing laparoscopic radical gastrectomy. While the N-methyl-D-aspartic acid receptor antagonist esketamine has demonstrated efficacy in enhancing sleep quality and alleviating postoperative pain, its impact on POFS remains uncertain. Consequently, the objective of this study is to ascertain whether perioperative administration of esketamine can effectively mitigate the occurrence of POFS in patients undergoing laparoscopic radical gastrectomy. METHODS A total of 133 patients diagnosed with gastric cancer were randomly assigned to two groups, namely the control group (Group C) (n = 66) and the esketamine group (Group E) (n = 67), using a double-blind method. The Group C received standardized anesthesia, while the Group E received esketamine in addition to the standardized anesthesia. The primary outcome measure assessed was the Christensen fatigue score at 3 days after the surgical procedure, while the secondary outcomes included the disparities in postoperative fatigue, postoperative pain, sleep quality, and adverse reactions between the two groups. RESULTS In the group receiving esketamine, the fatigue scores of Christensen on the third day after surgery were significantly lower compared to the Group C (estimated difference, -0.70; 95% CI, -1.37 to -0.03; P = 0.040). Additionally, there was a significant decrease in the occurrence of fatigue in the Group E compared to the Group C on the first and third days following surgery (P < 0.05). Also, compared to individuals who had distal gastrectomy, those who had entire gastrectomy demonstrated a higher degree of postoperative tiredness reduction with esketamine. Furthermore, the Group E exhibited reduced postoperative pain and improved sleep in comparison to the Group C. Both groups experienced similar rates of adverse events. CONCLUSIONS The use of esketamine during the perioperative period can improve POFS after laparoscopic radical gastrectomy, without adverse reactions. TRIAL REGISTRATION Registered in the Chinese Clinical Trial Registry (ChiCTR2300072167) on 05/06 /2023.
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Affiliation(s)
- Xinru Lin
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Xiaoxue Feng
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Linxiao Sun
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325000, China
| | - Yijian Wang
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Xudong Wu
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Shufang Lu
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Lulu Shao
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Wenchao Wang
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Liqun Yang
- Department of Anesthesiology Renji Hospital, Shanghai Jiaotong University School of Medicine, No.160 Pujian road, Shanghai, 200127, China.
| | - Wujun Geng
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China.
| | - Hai Lin
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China.
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Tankel J, Kammili A, Meng A, Dehghani M, Sakalla R, Spicer J, Najmeh S, Cools-Lartigue J, Ferri L, Mueller C. Enhanced recovery after surgery after radical gastrectomy: Improved compliance over time is associated with a shorter postoperative hospital stay. World J Surg 2024; 48:261-270. [PMID: 38686766 DOI: 10.1002/wjs.12055] [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: 11/07/2023] [Accepted: 12/07/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND Changing adherence over time to enhanced recovery after surgery (ERAS) protocols following radical gastrectomy and the impact this has on length of stay (LoS) is not well described. This study aimed to explore the changes in adherence to core ERAS elements over time and the relationship between compliance and LoS. METHODS A retrospective, single center cohort study was performed between 01/2016-12/2021. An ad hoc analysis revealed the point at which a significant difference in the number of patients being discharge on postoperative day (PoD) 3 was noted allowing allocation of patients to Group A (01/2016-12/2019) or B (01/2020-12/2021). Compliance with core ERAS elements was compared and the relationship between compliance and discharge by (PoD) 3 assessed. Variables significant on univariate analysis were assessed using binary multivariate regression. RESULTS Of the 268 patients identified, 187 met the inclusion criteria (Group A 112 and Group B 75). More patients in Group B mobilized on PoD 1 (60.0 vs. 31.3%, p = <0.001), tolerated postgastrectomy diet by PoD 3 (84.6 vs. 62.5%, p = 0.049), and were discharged by PoD 3 (34.7 vs. 20.5%, p = 0.002). Protocol compliance of >75% was associated with discharge on PoD 3 (area under the curve, 0.726). Active mobilization on PoD 1 (OR 3.5, p = 0.009), compliance ≥75% (OR 3.3, p = 0.036), and preoperative nutritional consult (OR 0.2, p = 0.002) were independently associated with discharge on PoD 3. Discharge on PoD 3 did not increase readmission or representation to hospital. CONCLUSION Early mobilization, protocol compliance >75%, and preoperative nutritional consult were associated with discharge on PoD 3 after radical gastrectomy.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anitha Kammili
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Meng
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mehrnoush Dehghani
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Rawan Sakalla
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Longitudinal Change in Symptom Clusters in Patients With Ovarian Cancer. THE JOURNAL OF NURSING RESEARCH : JNR 2022; 30:e196. [PMID: 35323132 DOI: 10.1097/jnr.0000000000000478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The symptoms of patients with ovarian cancer at a specific time point during the treatment process have been investigated in previous studies. However, only a few longitudinal studies have been conducted in China to determine the symptom cluster of patients with ovarian cancer before surgery, after surgery, and during the initial stage of chemotherapy. PURPOSE This study was carried out to identify the symptom clusters in patients with ovarian cancer at different stages of treatment. METHODS A longitudinal survey was designed, and 430 patients with ovarian cancer who had undergone surgical operation combined with chemotherapy were recruited as participants. Exploratory factor analysis was conducted to identify the components of symptom cluster at three different time points: 3 days before surgery (T1), 2 days after surgery (T2), and the first day after the completion of chemotherapy cycle 1 (T3). RESULTS The symptom clusters varied across the three time points. Notably, the pain-related, emotional, cognitive, and disease-related symptom clusters occurred at T1 and persisted through T2 and T3; the treatment-related symptom cluster occurred at T2 and persisted through T3; and the numbness symptom and gastrointestinal symptom clusters were observed at T3. CONCLUSIONS Priority symptom management interventions should be provided according to the most severe symptom clusters such as the emotional symptom cluster at T1, the treatment-related symptom cluster at T2, and the gastrointestinal symptom cluster at T3.
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Liu S, Cheng Y, Chen WZ, Lv JX, Zheng BS, Huang DD, Xia XF, Yu Z. Inflammation Disturbed the Tryptophan Catabolites in Hippocampus of Post-operative Fatigue Syndrome Rats via Indoleamine 2,3-Dioxygenas Enzyme and the Improvement Effect of Ginsenoside Rb1. Front Neurosci 2021; 15:652817. [PMID: 34512234 PMCID: PMC8427665 DOI: 10.3389/fnins.2021.652817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/02/2021] [Indexed: 11/17/2022] Open
Abstract
Aim Post-operative fatigue syndrome (POFS) is a common complication that prolongs the recovery to normal function and activity after surgery. The aim of the present study was to explore the mechanism of central fatigue in POFS and the anti-fatigue effect of ginsenoside Rb1. Method We investigated the association between inflammation, indoleamine 2,3-dioxygenase (IDO) enzyme, and tryptophan metabolism in the hippocampus of POFS rats. A POFS rat model was induced by major small intestinal resection. Rats with major small intestinal resection were administered ginsenoside Rb1 (15 mg/kg) once a day from 3 days before surgery to the day of sacrifice, or with saline as corresponding controls. Fatigue was assessed with the open field test (OFT) and sucrose preference test (SPT). ELISA, RT-PCR, Western blot, immunofluorescence, and high-performance liquid chromatography (HPLC) were used to test the inflammatory cytokines; p38MAPK, NF-κB/p65, and IDO enzyme expressions; and the concentrations of tryptophan, kynurenine, and serotonin, respectively. Result Our results showed that POFS was associated with increased expressions of inflammatory cytokines and p38MAPK and higher concentrations of kynurenine and tryptophan on post-operative days 1 and 3; a lower serotonin level on post-operative day 1; and an enhanced translocation of NF-κB/p65 and the IDO enzyme on post-operative days 1, 3, and 5. Ginsenoside Rb1 had an improvement effect on these. Conclusion Inflammatory cytokines induced by large abdominal surgery disturb tryptophan metabolism to cause POFS through the activation of the p38MAPK–NF-κB/p65–IDO pathway in the hippocampus. Ginsenoside Rb1 had an anti-fatigue effect on POFS by reducing inflammation and IDO enzyme.
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Affiliation(s)
- Shu Liu
- Department of Biomedical Sciences, College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
| | - Yue Cheng
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Wei-Zhe Chen
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin-Xiao Lv
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bei-Shi Zheng
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dong-Dong Huang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu-Fen Xia
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Zhen Yu
- Department of Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
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Jakobsen DH, Høgdall C, Seibæk L. Postoperative mobilisation as an indicator for the quality of surgical nursing care. ACTA ACUST UNITED AC 2021; 30:S4-S15. [PMID: 33641401 DOI: 10.12968/bjon.2021.30.4.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Postoperative mobilisation is an important part of fundamental care. Increased mobilisation has positive effect on recovery, but immobilisation is still a challenge in postoperative care. AIMS To report how the establishment of a national nursing database was used to measure postoperative mobilisation in patients undergoing surgery for ovarian cancer. METHODS 'Mobilisation' was defined as at least 3 hours out of bed on postoperative day 1, with the goal set at achieving this in 60% of patients. Data entry was performed by clinical nurses on 4400 patients with ovarian cancer. FINDINGS 46.7% of patients met the goal for mobilisation on the first postoperative day, but variations in duration and type of mobilisation were observed. Of those mobilised, 51.8% had been walking in the hallway. CONCLUSIONS A national nursing database creates opportunities to optimise fundamental care. By comparing nursing data with oncological, surgical and pathology data it became possible to study mobilisation in relation to cancer stage, comorbidity, treatment and extent of surgery.
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Affiliation(s)
- Dorthe Hjort Jakobsen
- Clinical Head Nurse, Section of Surgical Pathophysiology, Copenhagen University Hospital, Denmark
| | - Claus Høgdall
- Professor, Department of Gynecology, Rigshospitalet, Juliane Marie Centre, Copenhagen University Hospital, Denmark
| | - Lene Seibæk
- Associate professor, Department of Gynaecology and Obstetrics, Aarhus University Hospital, Denmark
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Enhanced Recovery Protocol Enhances Postdischarge Recovery After Laparoscopic Sacrocolpopexy. Female Pelvic Med Reconstr Surg 2021; 27:667-671. [PMID: 34171879 DOI: 10.1097/spv.0000000000001042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study is to determine if an ERAS (enhanced recovery after surgery) protocol enhanced the patient-perceived postdischarge recovery after laparoscopic sacrocolpopexy. METHODS In this prospective cohort study, patients exposed to an ERAS protocol completed a preoperative survey that included established predictors of postdischarge recovery. Postoperatively, they completed the validated Postdischarge Surgical Recovery 13 (PSR-13) scale at 7, 14, and 42 days. A historical cohort of non-ERAS patients who completed similar surveys were included for comparisons. Characteristics between the 2 cohorts were analyzed using the χ2 test, Student t tests, and Mann-Whitney U tests where appropriate. A mixed-design analysis of variance model was constructed to determine if our ERAS protocol affected recovery as measured by the PSR-13 scale. RESULTS Eighty-nine ERAS patients were compared with 169 non-ERAS controls. There were no differences in established predictors of recovery between the groups. Length of hospital stay was shorter in the ERAS cohort (33±13.1 hours vs 44.2±25.9 hours; mean difference, 11.2; 95% confidence interval [CI], 6.44-16.0). Postdischarge recovery significantly improved with time (7 days: 52.7; 95% CI, 50.1-55.2; 14 days: 63.4; 95% CI, 60.9-65.8; 42 days: 80.1, 95% CI, 78.1-82.1). The ERAS cohort reported greater postdischarge recovery than the non-ERAS cohort (as measured by the PSR-13 scale) at postoperative days 7, 14, and 42 days (68.4 vs 62.3; mean difference, 6.1; 95% CI, 2.04-10.16). CONCLUSIONS Enhanced recovery after surgery protocols reduce length of hospital stay and enhance patient-perceived postdischarge recovery.
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Hubert M, Gabriel D, El Khouda S, Coster M, Routiaux C, Hans G, Nihant N, Joris J. Energy and Protein Intake After Return Home in Colorectal Surgery Patients With an Enhanced Recovery Program: A Prospective Observational Study. Nutr Clin Pract 2021; 36:639-647. [PMID: 33410538 DOI: 10.1002/ncp.10617] [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: 06/29/2020] [Accepted: 11/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In patients scheduled for colorectal surgery with an enhanced recovery program (ERP), feeding after returning home has been insufficiently investigated. The aim of this study was to measure energy and protein intake during the first month at home. METHODS Seventy adult patients scheduled for colorectal surgery with ERP were included. Calorie and protein intakes were calculated, and body weight was measured preoperatively and 3, 7, 15, and 30 days after discharge home. Data are mean ± SD or median (interquartile range). RESULTS Patient characteristics were age 60.0 ± 15.0 years, BMI = 25.9 ± 5.5 kg/m2 , and colon/rectum of 56/14. The duration of hospitalization was 3 (2-5) days. Calorie and protein intakes (21.9 [17.7-28.6] kilocalorie per kilogram of ideal body weight [kcal/kg IBW] and 0.81 [0.61-1.14] g/kg IBW) were significantly reduced (P < .01) by 15% on day 3, compared with preoperative values, and then increased gradually to reach preoperative values after 1 month. Almost 50% of the patients failed to reach the calorie intake target of 25 kcal/kg IBW, and almost no patient reached the protein intake target of 1.5 g/kg IBW 30 days after discharge home. Weight loss after 30 days at home remained at -1.8 ± 2.7 kg. CONCLUSIONS Colorectal surgery, even in an ERP, is associated with energy and protein intake below the targets recommended for the rehabilitation phase and results in weight loss. Whether nutrition counseling and prolonged administration of protein-enriched oral supplements could accelerate weight gain needs to be explored.
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Affiliation(s)
- Mégane Hubert
- Department of Anesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium
| | - Dominique Gabriel
- Dietary and Nutrition Services, CHU Liège, University of Liège, Liège, Belgium
| | - Soraya El Khouda
- Dietary and Nutrition Services, CHU Liège, University of Liège, Liège, Belgium
| | - Marine Coster
- Haute Ecole de la Province de Liège, Dietetics Section, Jemeppe, Belgium
| | - Clara Routiaux
- Haute Ecole de la Province de Liège, Dietetics Section, Jemeppe, Belgium
| | - Gregory Hans
- Department of Anesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium
| | - Nicole Nihant
- Haute Ecole de la Province de Liège, Dietetics Section, Jemeppe, Belgium
| | - Jean Joris
- Department of Anesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium.,Groupe francophone de réhabilitation améliorée après chirurgie (GRACE; Francophone group for enhanced recovery after surgery), Beaumont, France
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Wennström B, Johansson A, Kalabic S, E-Son Loft AL, Skullman S, Bergh I. Patient experience of health and care when undergoing colorectal surgery within the ERAS program. Perioper Med (Lond) 2020; 9:15. [PMID: 32467753 PMCID: PMC7238535 DOI: 10.1186/s13741-020-00144-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/03/2020] [Indexed: 01/10/2023] Open
Abstract
Background Several studies show that the enhanced recovery after surgery (ERAS) program reduces complications postoperatively and leads to faster recovery and shorter hospital stays. However, little is known about patients’ self-reported health in an enhanced recovery context. The aim of this study was firstly to describe patient experiences of health within the concept of ERAS after colorectal (CR) surgery during a hospital stay and within 2 weeks of discharge. Secondly, to explore whether the ASA classification/co-morbidity, sex, and surgical method affect the patient’s experience of health. Methods Data were collected through the ERAS-HEALTH questionnaire, including two open-ended questions, and through telephone interviews postoperatively. Qualitative and quantitative analysis was used. Patients undergoing CR surgery (n = 80) were included from October 2016 to June 2018. Results The patients had mainly positive experiences of their hospital stay as well as most of them felt comfortable coming home. However, experienced state of health is affected by factors like surgical method and co-morbidity. Improvements were desired concerning information, food/food intake, pain management, and environment. At home, the patients experienced a lack of information about food/food intake and ostomy care. Decreased appetite and difficulties with micturition were also described. The most troublesome symptom was postoperative fatigue (POF). Analysis of the ERAS-HEALTH questionnaire showed that patients with higher co-morbidity and those who underwent open surgery have a significantly worse experience of their health compared with patients who underwent laparoscopy. However, it seems that the surgical method affects postoperative health to a greater extent than co-morbidity. Conclusions The patients reported many positive aspects and challenges when being cared for within the ERAS program. However, several improvements are needed to satisfy patient wishes regarding their care both in hospital and at home. Laparoscopic surgery affects patient state of health positively in several respects compared with open surgery.
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Affiliation(s)
- Berith Wennström
- 1Department of Anaesthesia, Skaraborg Hospital, Skövde, Sweden.,2School of Health Sciences, University of Skövde, Skövde, Sweden.,3Department of Surgery, Skaraborg Hospital, Skövde, Sweden.,4Research and Development Center, Skaraborg Hospital, Skövde, Sweden
| | - Anna Johansson
- 3Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Sabina Kalabic
- 3Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | | | | | - Ingrid Bergh
- 2School of Health Sciences, University of Skövde, Skövde, Sweden
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Dean HF, Carter F, Francis NK. Modern perioperative medicine - past, present, and future. Innov Surg Sci 2019; 4:123-131. [PMID: 33977121 PMCID: PMC8059350 DOI: 10.1515/iss-2019-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022] Open
Abstract
Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.
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Affiliation(s)
- Harry F. Dean
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - Fiona Carter
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil, UK
| | - Nader K. Francis
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, UK
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil BA20 2RH, UK
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK, Tel.: (01935) 384244
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Li D, Jensen CC. Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols. Clin Colon Rectal Surg 2019; 32:138-144. [PMID: 30833864 DOI: 10.1055/s-0038-1676480] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
While studies have demonstrated the benefits of Enhanced Recovery after Surgery (ERAS) programs in reducing length of stay and costs without increasing complications, fewer studies have evaluated patient satisfaction and quality of life (QOL) with enhanced recovery protocols. The aim of this project was to summarize the literature comparing satisfaction and quality of life after colorectal surgery following treatment within an ERAS protocol to standard postoperative care. The available evidence suggests patients suffer no detriment to satisfaction or quality of life with use of ERAS protocols, and may suffer less fatigue and return to activities sooner. Most publications reported no adverse effects on postoperative pain. However, a limited number of studies suggest patients may experience increased early postoperative pain with ERAS pathways, particularly following open colorectal procedures. Future research should focus on potential improvements in ERAS protocols to better manage postoperative pain. Overall, the evidence supports more widespread implementation of ERAS pathways in colorectal surgery.
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Affiliation(s)
- Debbie Li
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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The Relationship Between Nutritional Risks and Cancer-Related Fatigue in Patients With Colorectal Cancer Fast-Track Surgery. Cancer Nurs 2018; 41:E41-E47. [DOI: 10.1097/ncc.0000000000000541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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13
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Abstract
Enhanced recovery programs were developed as a means for improving patient recovery after surgery with a multifaceted approach including several interventions in the perioperative period. There is now sufficient evidence in the literature that enhanced recovery programs have actually shortened hospital length of stay after colorectal surgery. Nonetheless, the impact of these successful programs on patient-reported outcomes like functional recovery and return to baseline quality of life is not known.
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Xu B, Ma J, Huang Q, Huang ZY, Zhang SY, Pei FX. Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2018; 26:1549-1556. [PMID: 28474088 DOI: 10.1007/s00167-017-4506-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/01/2017] [Indexed: 11/30/2022]
Abstract
To study the clinical effect and safety of two doses of low-dose perioperative dexamethasone on pain and recovery after total knee arthroplasty. Methods A total of 108 patients were included in this randomized, double-blinded, placebo-controlled study. They received two doses of 10 mg IV dexamethasone (group Dexa) or IV isotonic saline (group Placebo). The CRP, IL-6 and pain levels, postoperative nausea and vomiting (PONV) incidence, nausea severity, postoperative fatigue, range of motion, length of stay, analgesic rescue and antiemetic rescue consumption, and complications were compared. Results The CRP and IL-6 levels in group Dexa were lower than in group Placebo at 24, 48, and 72 h postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). In group Dexa, patients had less pain at 24 h postoperatively, at rest (P < 0.001) and during walking (P < 0.001); they also had a lower PONV incidence (P = 0.002) and a lower nausea VAS score (P = 0.008). Postoperative fatigue (P < 0.001) was relieved and the analgesic and antiemetic rescue consumption was reduced. Length of stay (n.s.) and range of motion (n.s.) were similar in both groups. No early surgical wound infection or gastrointestinal haemorrhage occurred in either group. Conclusions Administering two doses of low-dose perioperative dexamethasone for patients receiving total knee arthroplasty reduces postoperative CRP and IL-6 levels, provides additional analgesic effect, and reduces the PONV incidence and postoperative fatigue, without increasing the risk of early surgical wound infection and gastrointestinal haemorrhage. So two doses of low-dose perioperative dexamethasone are effective and safe for patients receiving TKA to decrease the inflammatory response, prevent PONV, relieve postoperative pain and fatigue, and enhance recovery. Level of evidence I.
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Affiliation(s)
- Bin Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Jun Ma
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ze-Yu Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Shao-Yun Zhang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Fu-Xing Pei
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China.
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15
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Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties. Ann Surg 2017; 265:930-940. [PMID: 28398962 DOI: 10.1097/sla.0000000000001745] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery. BACKGROUND Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. METHODS Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). RESULTS There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. CONCLUSIONS Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.
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Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond) 2017; 6:4. [PMID: 28270910 PMCID: PMC5335800 DOI: 10.1186/s13741-017-0059-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections. METHODS With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients. DISCUSSION As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).
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Affiliation(s)
- Stefan D. Holubar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Traci Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - John Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark Hamilton
- Department of Intensive Care Medicine and Anaesthesia, St. George’s Hospital and Medical School, London, UK
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - Monty G. Mythen
- Department of Anesthesia, UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, TN USA
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
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Abeles A, Kwasnicki RM, Darzi A. Enhanced recovery after surgery: Current research insights and future direction. World J Gastrointest Surg 2017; 9:37-45. [PMID: 28289508 PMCID: PMC5329702 DOI: 10.4240/wjgs.v9.i2.37] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/14/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.
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Abstract
IMPORTANCE Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology. OBJECTIVE The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology. EVIDENCE ACQUISITION Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed. RESULTS Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life. CONCLUSIONS AND RELEVANCE High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.
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Wolthuis AM, Bislenghi G, Fieuws S, de Buck van Overstraeten A, Boeckxstaens G, D'Hoore A. Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2016; 18:O1-9. [PMID: 26558477 DOI: 10.1111/codi.13210] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 08/01/2015] [Indexed: 02/08/2023]
Abstract
AIM Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described. METHOD MEDLINE, Embase and the Cochrane Database of Systematic Reviews (up to July 2014) were searched. Two authors independently reviewed citations using predefined inclusion and exclusion criteria. RESULTS The search strategy yielded 3233 citations; 54 were eligible, comprising 18 983 patients. Twenty-six studies were prospective [17 of these being randomized controlled trials (RCTs)] and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3% (95% CI 8.4-12.5) and 10.2% (95% CI 5.6-17.8) for non-RCTs and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for RCTs. The used definition of PPOI, the type of surgery and access (laparoscopic, open) and the duration of surgery lead to significant variability of reported PPOI incidence between studies. The incidence of PPOI is lower after laparoscopic colonic resection. CONCLUSION There is a large variation in the reported incidence of PPOI. A uniform definition of PPOI is needed to allow meaningful inter-study comparisons and to evaluate strategies to prevent PPOI.
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Affiliation(s)
- A M Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - G Bislenghi
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - S Fieuws
- KU Leuven - University of Leuven and Universiteit Hasselt, Interuniversity Center for Biostatistics and Statistical Bioinformatics, Leuven, Belgium
| | | | - G Boeckxstaens
- KU Leuven - Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Leuven, Belgium
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
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20
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Day RW, Aloia TA. Clinical Care Pathways in Cancer Surgery. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Fei Y, Zong GQ, Chen J, Liu RM. Fast-track protocols in devascularization for cirrhotic portal hypertension. Rev Assoc Med Bras (1992) 2015; 61:250-7. [PMID: 26248248 DOI: 10.1590/1806-9282.61.03.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 10/22/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION/OBJECTIVE fast-tract surgery (FTS) has been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. The aim of this study was to determine if any improvement in outcomes occurred after FTS protocol for selective double portazygous disconnection with preserving vagus (SDPDPV) compared with non-FTS postoperative care. METHODS patients eligible for SDPDPV in the period January 2012-April 2014 were randomly selected for the FTS group or non-FTS group. A designed protocol was used in the FTS group with emphasis on an interdisciplinary approach. The non-FTS group was treated using previously established standard procedures. The number of postoperative complications, time of functional recovery and duration of hospital stay were recorded. RESULTS patients in the FTS group (n=59) and non-FTS group (n=57) did not differ in terms of preoperative data and operative details (p>0.05). The FTS procedure led to significantly better control and faster restoration of gastrointestinal functions, food tolerance, rehabilitation and hospital discharge (p<0.05). Postoperative complications, including nausea/vomiting, severe ascites, wound infection, urinary tract infection and pulmonary infection were all significantly lower in the FTS group (p<0.05). According to the postoperative morbidity classification used by Clavien, overall complications and grade I complications were both significantly lower in the FTS group compared with the non-FTS group (p<0.05). CONCLUSION adopting the FTS protocol helped to recover gastrointestinal functions, to reduce frequency of postoperative complications and to reduce hospital stay. The FTS strategy is safe and effective in improving postoperative outcomes.
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Affiliation(s)
- Yang Fei
- Department of General Surgery, 81st Hospital of P.L.A., Nanjing, China
| | - Guang-quan Zong
- Department of General Surgery, 81st Hospital of P.L.A., Nanjing, China
| | - Jian Chen
- Department of General Surgery, 81st Hospital of P.L.A., Nanjing, China
| | - Ren-min Liu
- Department of General Surgery, 81st Hospital of P.L.A., Nanjing, China
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Wang H, Zhu D, Liang L, Ye L, Lin Q, Zhong Y, Wei Y, Ren L, Xu J, Qin X. Short-term quality of life in patients undergoing colonic surgery using enhanced recovery after surgery program versus conventional perioperative management. Qual Life Res 2015; 24:2663-70. [DOI: 10.1007/s11136-015-0996-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 12/22/2022]
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Yu J, Zhuang CL, Shao SJ, Liu S, Chen WZ, Chen BC, Shen X, Yu Z. Risk factors for postoperative fatigue after gastrointestinal surgery. J Surg Res 2015; 194:114-9. [DOI: 10.1016/j.jss.2014.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/31/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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Anesthesia type and perioperative outcome: open colectomies in the United States. J Surg Res 2015; 193:684-92. [DOI: 10.1016/j.jss.2014.08.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 07/31/2014] [Accepted: 08/28/2014] [Indexed: 01/31/2023]
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Shelygin YA, Achkasov SI, Lukashevich IV. [Optimization of postoperative period in patients after colon resection]. Khirurgiia (Mosk) 2015:76-81. [PMID: 26103648 DOI: 10.17116/hirurgia2015476-81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Yu A Shelygin
- State Scientific Coloproctology Center of Russian Medical Academy of Postgraduate Education
| | - S I Achkasov
- State Scientific Coloproctology Center, Health Ministry of the Russian Federation, Moscow
| | - I V Lukashevich
- State Scientific Coloproctology Center, Health Ministry of the Russian Federation, Moscow
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Thomsen T, Vester-Andersen M, Nielsen MV, Waldau T, Møller AM, Rosenberg J, Møller MH, Nystrup KB, Esbensen BA. Patients' experiences of postoperative intermediate care and standard surgical ward care after emergency abdominal surgery: a qualitative sub-study of the Incare trial. J Clin Nurs 2014; 24:1280-8. [PMID: 25430728 DOI: 10.1111/jocn.12727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2014] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND Emergency abdominal surgery is common, but little is known about how patients experience postoperative care. The patient population is generally older with multiple comorbidities, and the short-term postoperative mortality rate is 15-20%. Thus, vigilant surgeon and nursing attention is essential. The present study is a qualitative sub-study of a randomised trial evaluating postoperative intermediate care after emergency abdominal surgery, the InCare trial. DESIGN A qualitative study with individual semi-structured interviews. METHODS We analysed interviews using Systematic Text Condensation. RESULTS Eighteen patients (nine intervention/nine controls) were strategically sampled from the InCare trial. Data analysis resulted in three distinct descriptions of intermediate care; two of standard surgical ward care. Intermediate care was described as 'luxury service' or 'a life saver.' The latter description was prevalent among patients with a perceived complicated disease course. Intermediate care patients felt constrained by continuous monitoring of vital signs as they recovered from surgery. Standard surgical ward care was described as either 'ok - no more, no less' or 'suboptimal'. Experiencing suboptimal care was related to patient perceptions of heavy staff workloads, lack of staff availability and subsequent concerns about the quality of care. CONCLUSION Postoperative intermediate care enhanced perceptions of quality of care, specifically in patients with a perceived complicated disease course. Patients were eager to contribute actively to their recovery; however, intermediate care patients felt hindered in doing so by continuous monitoring of vital signs. RELEVANCE TO CLINICAL PRACTICE Intermediate care may increase patient perceptions of quality and safety of care.
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Affiliation(s)
- Thordis Thomsen
- Abdominal Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014; 2014:CD009161. [PMID: 25121931 PMCID: PMC11060647 DOI: 10.1002/14651858.cd009161.pub2] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast-track surgery protocols. Although fast-track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. OBJECTIVES To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. SELECTION CRITERIA We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. DATA COLLECTION AND ANALYSIS Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. MAIN RESULTS We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I-II or I-III.A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding.In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low-quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference -0.13 days; 95% CI -0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high-quality evidence).As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low-quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. AUTHORS' CONCLUSIONS Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases.
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Affiliation(s)
- Mark D Smith
- Southland HospitalDepartment of General SurgeryKew RoadInvercargillNew Zealand9840
| | - John McCall
- Dunedin School of Medicine, University of OtagoDepartment of Surgical SciencesPO Box 913DunedinNew Zealand9054
| | - Lindsay Plank
- University of AucklandDepartment of SurgeryPrivate Bag 92019AucklandNew Zealand1142
| | - G Peter Herbison
- Dunedin School of Medicine, University of OtagoDepartment of Preventive & Social MedicinePO Box 913DunedinNew Zealand9054
| | - Mattias Soop
- Salford Royal NHS Foundation TrustDepartment of SurgeryStott LaneSalfordUK
| | - Jonas Nygren
- Institution of Clinical Sciences at Danderyds HospitalCentre for Gastrointestinal Disease, Ersta Hospital and Karolinska InstitutetStockholmSweden
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Hjort Jakobsen D, Rud K, Kehlet H, Egerod I. Standardising fast-track surgical nursing care in Denmark. ACTA ACUST UNITED AC 2014; 23:471-6. [PMID: 24820811 DOI: 10.12968/bjon.2014.23.9.471] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the 'workshop practice method': establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care.
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Affiliation(s)
| | - Kirsten Rud
- Head Nurse at the Unit of Perioperative Nursing, Rigshospitalet
| | - Henrik Kehlet
- Professor at the Section of Surgical Pathophysiology, Rigshospitalet
| | - Ingrid Egerod
- Professor at the Trauma Centre, Rigshospitalet, Copenhagen, and the Faculty of Health and Medicine, University of Copenhagen, Denmark
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Ginsenoside Rb1 improves energy metabolism in the skeletal muscle of an animal model of postoperative fatigue syndrome. J Surg Res 2014; 191:344-9. [PMID: 24881470 DOI: 10.1016/j.jss.2014.04.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/11/2014] [Accepted: 04/24/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Postoperative fatigue syndrome (POFS) is a common clinical complication followed by almost every major abdominal surgery. Ginsenoside Rb1 (GRb1), a principle ginsenoside in ginseng, could exert a potent anti-fatigue effect on POFS. However, the mechanism is still unknown. Previous studies revealed that alterations in the energy metabolism in the skeletal muscle may play a vital role in the development and progression of fatigue. In the present study, we investigate the effect of GRb1 on energy metabolism in the skeletal muscle of a rat model of POFS induced by major small intestinal resection. METHODS GRb1 (10 mg/kg) was intraperitoneally administrated once daily for 1, 3, 7, and 10 d from the operation day, respectively. The locomotor activity was recorded every day, and total food intake was calculated starting from 24 h after surgery. After GRb1 treatment was completed, blood and skeletal muscle were sampled. The level of blood glucose was determined by an automatic biochemical analyzer. The content of adenosine triphosphate (ATP) in skeletal muscle was determined by high-performance liquid chromatography. The activity of energy metabolic enzymes Na(+)-K(+)-ATPase, pyruvate kinase, and succinate dehydrogenase (SDH) was assessed by commercially available kits. RESULTS The results revealed that GRb1 could increase locomotor activity of POFS rats and significantly increase their total food intake postoperatively (P < 0.05). Furthermore, GRb1 also significantly increased ATP content in the skeletal muscle of POFS rats (P < 0.05). Meanwhile, the activity of Na(+)-K(+)-ATPase and SDH in the skeletal muscle of POFS rats was enhanced by GRb1 (P < 0.05). However, no significant differences in blood glucose and pyruvate kinase were found between the POFS and GRb1 treatment rats (P > 0.05). CONCLUSIONS These results suggest that GRb1 may improve skeletal muscle energy metabolism in POFS, and the underlying mechanism may be associated with an increase in the content of ATP and an enhancement in the activity of energy metabolic enzymes such as Na(+)-K(+)-ATPase ATPase and SDH in the skeletal muscle.
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Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS. Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 2014; 101:159-70. [PMID: 24469616 DOI: 10.1002/bjs.9324] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies. METHODS A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge). RESULTS A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission. CONCLUSION Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.
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Affiliation(s)
- A Neville
- Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, and Department of Surgery, McGill University, Montreal, Canada
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Hill AG. Recovery after abdominal surgery: the peritoneum may be a key therapeutic target. ANZ J Surg 2014; 83:898-9. [PMID: 24436955 DOI: 10.1111/ans.12247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:259-84. [PMID: 23052794 DOI: 10.1007/s00268-012-1772-0] [Citation(s) in RCA: 819] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:285-305. [PMID: 23052796 DOI: 10.1007/s00268-012-1787-6] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Khan SA, Ullah S, Ahmed J, Wilson TR, McNaught C, Hartley J, Macfie J. Influence of enhanced recovery after surgery pathways and laparoscopic surgery on health-related quality of life. Colorectal Dis 2013; 15:900-7. [PMID: 23528230 DOI: 10.1111/codi.12191] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/17/2012] [Indexed: 02/08/2023]
Abstract
AIM This study set out to compare the postoperative health related quality of life (HQoL) of patients undergoing elective open colorectal surgery using a well-established enhanced recovery after surgery (ERAS) pathway with those undergoing laparoscopic surgery without an established an ERAS pathway. METHOD Using a power calculation, it was estimated that 40 patients would be required in each group. HQoL of the two groups was prospectively assessed using SF-12 (Short Form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at 2 and 6 weeks after discharge. RESULTS Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open-ERAS group. There was a significant difference between the median length of stay of the open-ERAS (5 days) and laparoscopic (7 days, P = 0.028) groups. There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL scores had improved considerably by 6 weeks. CONCLUSION Laparoscopic and open-ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6-week stage.
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Affiliation(s)
- S A Khan
- Combined Gastroenterology Research Unit, Scarborough General Hospital, Scarborough, Yorkshire, UK
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Bianchini C, Pelucchi S, Pastore A, Feo CV, Ciorba A. Enhanced recovery after surgery (ERAS) strategies: possible advantages also for head and neck surgery patients? Eur Arch Otorhinolaryngol 2013; 271:439-43. [PMID: 23616139 DOI: 10.1007/s00405-013-2502-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 04/16/2013] [Indexed: 12/15/2022]
Abstract
Enhanced recovery after surgery (ERAS) programs have recently been developed in order to reduce morbidity, improve recovery, and shorten hospital stays of surgical patients. Since the 1990 s, ERAS programs have been successfully applied in many centres, especially in northern Europe and America, to perioperative management for colorectal surgery, vascular surgery, thoracic surgery, and then also to urological and gynaecologic surgery. Purpose of this paper is to evaluate and discuss the very recent introduction of ERAS programs also in head and neck surgery. Embase and Pubmed database searches were performed for relevant published studies. There are still no reports concerning the results of the application of ERAS protocols in the head and neck field. ERAS programs, however, could offer also to head and neck surgery patients an advantage in terms of fastening recovery, reducing hospital stay, and favouring early return to daily activities after hospital discharge. Therefore, the investigation of specific ERAS protocol in head and neck surgery patients should be encouraged.
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Affiliation(s)
- Chiara Bianchini
- ENT and Audiology Department, University of Ferrara and S. Anna University Hospital, C.so Giovecca 203, 44100, Ferrara, Italy,
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Wodlin NB, Nilsson L. The development of fast-track principles in gynecological surgery. Acta Obstet Gynecol Scand 2012; 92:17-27. [PMID: 22880948 DOI: 10.1111/j.1600-0412.2012.01525.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.
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Affiliation(s)
- Ninnie Borendal Wodlin
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:783-800. [PMID: 23099039 DOI: 10.1016/j.clnu.2012.08.013] [Citation(s) in RCA: 445] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/19/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Ersta Hospital, Stockholm, Sweden.
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:801-16. [PMID: 23062720 DOI: 10.1016/j.clnu.2012.08.012] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.
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Affiliation(s)
- J Nygren
- Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.
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Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 2012; 36:63-72. [PMID: 22002193 DOI: 10.1097/aap.0b013e31820307f7] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs.In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements of fast-track methodologies, were identified. The impact of epidural and paravertebral blockade, spinal analgesia, peripheral nerve blocks, and new regional anesthesia techniques on main procedure-specific postoperative outcomes is discussed. Finally, in the last section, implementations required to improve the role of regional anesthesia in the context of fast-track programs are suggested, and issues not yet addressed are presented.
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A meta-analysis of the effectiveness of the opioid receptor antagonist alvimopan in reducing hospital length of stay and time to GI recovery in patients enrolled in a standardized accelerated recovery program after abdominal surgery. Dis Colon Rectum 2012; 55:611-20. [PMID: 22513441 DOI: 10.1097/dcr.0b013e318249fc78] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite accelerated recovery programs and the widespread uptake of laparoscopic surgery, postoperative ileus remains a significant factor affecting length of stay after abdominal surgery. Alvimopan, an opioid-receptor antagonist, may reduce the incidence of postoperative ileus and expedite hospital discharge. OBJECTIVE The aim of this study was to perform a meta-analysis to determine the role of alvimopan in accelerating GI recovery and hospital discharge after laparoscopic and open abdominal surgery performed within an accelerated recovery program. DATA SOURCES AND STUDY SELECTION Cochrane (1999-2010), Embase (1980-2010), MEDLINE (1980-2010), and International Pharmaceutical Abstracts (1970-2010) were searched for relevant double-blinded, randomized controlled trials. INTERVENTIONS Twelve milligrams of alvimopan and placebo were given to patients enrolled in an accelerated recovery program after abdominal surgery. MAIN OUTCOME MEASURES The primary outcomes measured were the length of stay as defined by the writing of the hospital discharge order and GI-3 and GI-2 GI tract recovery. RESULTS : Three trials were included that reported on a pooled modified intention-to-treat population of 1388 patients; 685 (49%) patients received alvimopan. On meta-analysis, alvimopan reduced time to the hospital discharge order (HR 1.37 (1.21, 1.62), p < 0.0001), GI-3 recovery (HR 1.42 (1.25, 1.62), p < 0.001), and GI-2 recovery (HR 1.49 (1.32, 1.68), p < 0.0001). LIMITATIONS The search criteria identified only a small number of trials of alvimopan after abdominal surgery with no randomized trials of alvimopan after laparoscopic surgery. In addition, the use of length of hospital stay as the primary outcome measure may be inappropriate, because it is open to many confounding factors. Finally, adverse events, in particular, adverse cardiovascular events, were not considered. CONCLUSIONS Alvimopan 12 mg can further reduce time to GI recovery and hospital discharge in patients undergoing abdominal surgery within an accelerated recovery program. Investigation into the effect of alvimopan following laparoscopic surgery and additional cost-benefit analyses are required to further define the role of this intervention.
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Fiore JF, Browning L, Bialocerkowski A, Gruen RL, Faragher IG, Denehy L. Hospital discharge criteria following colorectal surgery: a systematic review. Colorectal Dis 2012; 14:270-81. [PMID: 20977587 DOI: 10.1111/j.1463-1318.2010.02477.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature. METHODS A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study. RESULTS The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined. CONCLUSION A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.
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Affiliation(s)
- J F Fiore
- Melbourne School of Health Sciences, The University of Melbourne, Victoria, Australia.
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Zhang XD, Chen BC, Dong QT, Andersson R, Pan XD, Tan SJ, Ye XZ, Yao JG, Yu Z. Establishment and assessments of a new model for the postoperative fatigue syndrome by major small intestinal resection in rats. Scand J Gastroenterol 2011; 46:1302-9. [PMID: 21854092 DOI: 10.3109/00365521.2011.610001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Postoperative fatigue syndrome (POFS) is a general and main complication after surgery. However, there is no stable and standardized animal model for POFS. The aim of the present study was to establish a rodent model of POFS by small intestinal resection, with POFS evaluated by acknowledged physical and behavioral methods. MATERIAL AND METHODS Forty-two Sprague-Dawley rats were randomly divided into four groups according to the length of a "middle" small intestinal resection: 0% (sham group; i.e., laparotomy alone), 10%, 40% and 70% groups, with corresponding lengths of small intestinal resections. Following surgery, the general state of health was evaluated. Tail suspension test, open field test and Morris water maze test were used to evaluate the degree of POFS. Serum albumin, transferrin, prealbumin and fibronectin were measured to assess the nutritional status, and superoxide dismutase (SOD) and malondialdehyde (MDA) were also measured. RESULTS As compared with the other three groups, the 70% small intestinal resection group showed the worst general state of health, decreased strength of the tail suspension test and decreased score of Morris water maze test (p < 0.05) after operation. All rats in whom the small intestinal resection was done demonstrated a certain degree of malnutrition and behavior of depression, and the 70% resection group had the lowest levels of transferrin, prealbumin and fibronectin as compared with the other groups (p < 0.05), as well as decreased SOD and increased MDA in serum (p < 0.05). CONCLUSIONS Resection of 70% of the small intestine resulted in typical characteristics of POFS. As this procedure is simple, stable and easily reproducible, it may serve as a model for research on POFS.
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Affiliation(s)
- Xiao-Dong Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, China
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Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, Harmsen WS, Huebner M, Larson DW. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 2011; 99:120-6. [PMID: 21948187 DOI: 10.1002/bjs.7692] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations. METHODS An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared. RESULTS Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2-3) versus 3 (3-5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1-2) versus 2 (2-3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days). CONCLUSION ERP decreased the length of hospital stay after minimally invasive colorectal surgery.
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Affiliation(s)
- J K Lovely
- Hospital Pharmacy Services, Division of Colon and Rectal Surgery, 200 First Street SW, Rochester, Minnesota 55905, USA
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Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial. Ann Surg 2011; 254:28-38. [PMID: 21670611 DOI: 10.1097/sla.0b013e318221f0cf] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Two wounds are created after abdominal surgery. The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions. In animal models vagotomy blunts the intraperitoneal response to induced inflammation. This is not feasible in humans. However a transient chemical afferentectomy after colectomy by using neuraxial blockade (epidural) and intraperitoneal blockade may be possible. We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic (IPLA) on recovery parameters after colectomy, in the setting of an established enhanced recovery after surgery (ERAS) program. METHODS Double blinded, randomized, placebo controlled design. The study group (IPLA) received instillation of intraperitoneal ropivacaine (75 mg) before dissection and postoperative infusion of 0.2% solution at 4 mL/hour for 3 days continuously. The placebo group (NS) was treated as above with 0.9% saline solution. All patients were cared for under ERAS standardized perioperative care. Epidural infusion was stopped on day 2. Patients were discharged from day 3 onwards once criteria met. Perioperative data, surgical recovery score (SRS), complications, and length of stay were recorded. Systemic cytokines response, neuroendocrine parameters, pain measures and opioid use data were collected. Patients were followed up for 60 days. RESULTS Sixty patients were recruited. Patients were equivalently matched at baseline. There were no local anesthetic related adverse events. The complication rate, including anastomotic leak rate, was equivalent between groups. IPLA group had better SRS scores for the duration of intraperitoneal infusion. Pain and opioid use was reduced in the IPLA group. Systemic cytokine and cortisol response was diminished in the IPLA group. IPLA group had consistently higher systemic ropivacaine levels than placebo group. CONCLUSION Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery. This was associated with a blunting of postsurgical systemic cytokines and cortisol. Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion. Therefore a transient chemical afferentectomy with clinical benefit is possible with this method. A longer IPLA infusion duration needs to be studied. This study is registered at clinicaltrials.gov and carries the ID number NCT00722709.
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Abstract
PURPOSE OF REVIEW The review aims to highlight the importance of acute gastrointestinal failure in the postoperative patient, to clarify the clinical circumstances in which acute intestinal failure complicates postoperative management, and to discuss recent advances and controversy in our understanding of the cause and pathogenesis. RECENT FINDINGS Acute postoperative intestinal failure ranges from a self-limiting condition of disordered intestinal peristaltic activity, through to a complex critical illness state associated with abdominal sepsis and intestinal fistulation. Recent developments have focused on the mechanisms of paralytic ileus and preventive strategies, usually as part of programmes of 'fast-track' or 'enhanced recovery' care, and on the optimum management of patients with severe abdominal sepsis, including planned versus on-demand relaparotomy, open abdominal management of severe sepsis and negative pressure wound therapy. SUMMARY Many cases of acute intestinal failure are preventable. Improvements in understanding and preventing paralytic ileus through changes in postoperative care may facilitate recovery of gastrointestinal function after abdominal surgery. Further and better-organized studies are needed to define the optimum strategies for treating patients with severe abdominal sepsis, managing the patient with the open abdomen and defining the role of enteral, as opposed to parenteral nutritional support in such patients.
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Affiliation(s)
- Gordon L Carlson
- National Intestinal Rehabilitation Centre, Department of Surgery, UK.
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46
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Kahokehr AA, Zargar-Shoshtari K, Sammour T, Srinivasa S, Hill AG. Fatigue postopératoire : mythe ou réalité. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.pratan.2010.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Paddison JS, Sammour T, Kahokehr A, Zargar-Shoshtari K, Hill AG. Development and validation of the Surgical Recovery Scale (SRS). J Surg Res 2011; 167:e85-91. [PMID: 21392804 DOI: 10.1016/j.jss.2010.12.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/24/2010] [Accepted: 12/29/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND At the present, no fully validated instrument is available for the assessment of general postoperative recovery. Such an instrument would form a useful patient-centered outcome measure in studies evaluating surgical and perioperative interventions. The aim of our study is to develop and validate a summary score based on the Identity Consequence Fatigue Scale (ICFS), for the specific purpose of reliably measuring functional patient recovery following surgery. METHODS Patients who underwent elective open or laparoscopic colonic resection between June 2006 and June 2009 were included. The 31 item ICFS was administered at baseline and postoperative d 3, 7, 30, and 60. Item reduction was applied based on defined parameters, to derive a single summary score capable of predicting >90% of the variance present in the original ICFS and maximizing sensitivity to changes over time. The final score was then validated against published criteria as set out by Terwee et al. [2]. RESULT Data from 150 patients were included in the analysis. Application of the item reduction process retained 13 items. These items form the Surgical Recovery Scale (SRS). The SRS was able to predict 94% (89.4%-98.1%) of the ICFS subscale variances, and was successfully validated against seven out of eight published validation criteria. CONCLUSION The new SRS is a simple and sensitive tool for the assessment of functional recovery following major surgery. Seven of the eight Terwee et al. validation criteria have been addressed, making this the most broadly validated measure of surgical recovery available.
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Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of life and patient satisfaction with enhanced recovery protocols. Colorectal Dis 2010; 12:1175-82. [PMID: 19594603 DOI: 10.1111/j.1463-1318.2009.01997.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study was to systematically review the literature on the influence of enhanced recovery after surgery (ERAS) protocols and health related quality of life (HQoL) and patient satisfaction. METHOD A systematic review of the literature from January 1990 to February 2009 was undertaken. Studies were included if they compared HQoL and/or patient satisfaction after ERAS and conventional surgery (CS). Jadad score was used to evaluate the studies. Results were divided into immediate (first week), early (second to third week) and late (more than 30 days after surgery) post-operative phases. A meta-analysis was not possible due to the heterogeneity of the studies. RESULTS Ten publications were included in the final analysis. In the first week after surgery, two non-randomised trials found reduced fatigue and another 2 non-randomised studies found reduced pain with ERAS. One randomised study found increased emotional distress on SF36 in ERAS patients. At two to three weeks after surgery, none of the multidimensional HQoL measures showed any differences. Increased fatigue was reported with CS in 2 studies. Limitations in activities of daily living were more marked after CS in one study. Beyond 30 days after surgery, none of the HQoL measures showed any differences. Only one non-randomised study compared patient satisfaction after ERAS and CS and no difference was found. CONCLUSION There is no evidence that ERAS adversely affect HQoL or patient satisfaction. Certain aspects of HQoL such as pain and fatigue may improve with ERAS. Further research is required, especially in the early post-operative period.
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Affiliation(s)
- S Khan
- The Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK
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Enhanced Recovery After Surgery (ERAS) Protocols Must Be Considered When Determining Optimal Perioperative Care in Colorectal Surgery. Ann Surg 2010. [DOI: 10.1097/sla.0b013e3181e9d97b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG. The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis. J Surg Res 2010; 164:28-37. [PMID: 20828745 DOI: 10.1016/j.jss.2010.05.046] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 04/15/2010] [Accepted: 05/20/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery. MATERIALS AND METHODS A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0. RESULTS Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis. CONCLUSION Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.
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Affiliation(s)
- Tarik Sammour
- Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand.
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