Enhanced Recovery After Surgery and Its Effects on Patient Reported Outcomes

Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

INTRODUCTION

Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.

METHODS

Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.

RESULTS

Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).

CONCLUSION

This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.

The Quality of Life of Patients with Colorectal Carcinoma and Stoma

Surgical treatment and formation of a stoma can be lifesaving for colorectal cancer patients. However, the quality of life is often impaired in patients with stoma. The goal of this study is to determine the quality of life of patients with stoma and cancer, and the relationship between the quality of life and characteristics of these patients.

The study was conducted from 2018 to 2020 and included a total of 64 patients of both sexes with colorectal cancer and temporary or permanent stoma. The European Organization for Research and Treatment of Cancer with Quality of Life Questionnaire (EORTC QLQC29-30) and the anonymous WHO Quality of Life Questionnaire SF-36 were used for self-assessment of quality of life.

Our study included 39 (61.0%) men and 25 (39.0%) women. 24 patients (37.5%) had colostomy, 14 patients (21.9%) had ileostomy, and 26 patients (40.6%) underwent surgery for resection of colorectal cancer without stoma. A significant number of women were in the group of patients with a permanent stoma (p = 0.01). There was no statistically significant difference in the assessment of general health (p = 0.680) and quality of life (p = 0.721) during the past month in relation to gender. Patients without a stoma rated their general health better compared to those with stoma and the difference reached statistical significance (p = 0.035). There was no statistically significant difference in the assessment of quality of life between the group of patients with stoma and without stoma, as well as between the patients of different age groups.

Patients with stoma rated their general health as worse, but not their quality of life.

Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme

Background

Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated.

Method

Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified.

Results

Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome.

Conclusions

The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.

[Effectiveness of pronator quadratus muscle sparing in volar plate fixation for unstable distal radius fracture in adults]

OBJECTIVE

To investigate the effectiveness of pronator quadratus muscle sparing in volar plate fixation for unstable distal radius fracture in adults.

METHODS

The clinical data of 62 cases of unstable distal radius fractures between January 2017 and December 2018 were retrospectively analyzed. According to the different methods of intraoperative exposure, the patients were divided into the observe group (28 cases with the pronator quadratus muscle sparing surgery) and the control group (32 cases with cutting the pronator quadratus muscle in operation and repairing it after volar plate fixation). There was no significant difference in general data such as gender, age, handedness, cause of injury, fracture classification, time from injury to operation, visual analogue scale (VAS) score, and range of motion (ROM) of wrist (flexion, extension, pronation, and supination) before operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, fracture healing time, and postoperative complications were recorded and compared between the two groups. VAS score and ROM of wrist of two groups before operation and at 3 days and 3 months after operation were calculated and compared. The wrist function was evaluated according to the Krimmer evaluation criteria at 6 months after operation.

RESULTS

There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). The postoperative hospital stay and fracture healing time of the observe group were significantly shorter than those of the control group ( P<0.05). Patients in both groups were followed up 6-30 months, with an average of 13 months. The VAS score and ROM of wrist of the observe group at 3 days after operation were superior to the control group ( P<0.05), but there was no significant difference between the two groups at 3 months after operation ( P>0.05). At 6 months after operation, according to Krimmer evaluation criteria, the wrist function of the observe group was excellent in 21 cases and good in 7 cases, with an excellent and good rate of 100%; and the wrist function of the control group was excellent in 22 cases, good in 11 cases, and fair in 1 case, with an excellent and good rate of 97.1%. There was no significant difference in wrist function between the two groups ( χ 2=1.344, P=0.511). One case of poor incision healing occurred in the observe group, and 7 cases of poor incision healing and 5 cases of tendon pain occurred in the control group after operation. The incidence of postoperative complications was less in the observe group (3.6%) than in the control group (35.3%) ( χ 2=9.325, P=0.002).

CONCLUSION

It is feasible of the pronator quadratus muscle sparing in the volar plate fixation for unstable distal radius fracture in adults. It is beneficial to recover wrist function early after operation, reduce postoperative complications, shorten the length of hospitalization, protect the soft tissue of fracture site, and promote fracture healing.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study

BACKGROUND

Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT).

METHODS

In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs.

RESULTS

Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups.

CONCLUSIONS

Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.