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Grasso G, Noto M, Pescatori L, Sallì M, Kim HS, Teresi G, Torregrossa F. Enhanced Recovery after Cranial Surgery in Elderly: A Review. World Neurosurg 2024; 185:e1013-e1018. [PMID: 38467372 DOI: 10.1016/j.wneu.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| | - Manfredi Noto
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | | | - Marcello Sallì
- Rehabilitation Medicine Outpatient Department, A.S.P. Palermo, Palermo, Italy
| | - Hyeun-Sung Kim
- Department of Spine Surgery, Nanoori Gangnam Hospital, Seoul, South Korea
| | - Gaia Teresi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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Paladini A, Rawal N, Coca Martinez M, Trifa M, Montero A, Pergolizzi J, Pasqualucci A, Narvaez Tamayo MA, Varrassi G, De Leon Casasola O. Advances in the Management of Acute Postsurgical Pain: A Review. Cureus 2023; 15:e42974. [PMID: 37671225 PMCID: PMC10475855 DOI: 10.7759/cureus.42974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.
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Affiliation(s)
- Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
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Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2023; 5:CD013259. [PMID: 37162250 PMCID: PMC10171468 DOI: 10.1002/14651858.cd013259.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes. OBJECTIVES To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible. MAIN RESULTS We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies. AUTHORS' CONCLUSIONS Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.
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Affiliation(s)
| | | | | | - Rudi Mh Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
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4
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Wang X, Chen R, Ge L, Gu Y, Zhang L, Wang L, Zhuang C, Wu Q. Effect of short-term prehabilitation of older patients with colorectal cancer: A propensity score-matched analysis. Front Oncol 2023; 13:1076835. [PMID: 36874123 PMCID: PMC9978335 DOI: 10.3389/fonc.2023.1076835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
Objective The aim of this study was to assess the impact of short-term, hospital-based, supervised multimodal prehabilitation on elderly patients with colorectal cancer. Methods A single-center, retrospective study was conducted from October 2020 to December 2021, which included a total of 587 CRC patients who were scheduled to undergo radical resection. A propensity score-matching analysis was performed to reduce selection bias. All patients were treated within a standardized enhanced recovery pathway, and patients in the prehabilitation group received an additional supervised, short-term multimodal preoperative prehabilitation intervention. Short-term outcomes were compared between the two groups. Results Among the participants, 62 patients were excluded; 95 participants were included in the prehabilitation group and 430 in the non-prehabilitation group. After PSM analysis, 95 pairs of well-matched patients were included in the comparative study. Participants in the prehabilitation group had better preoperative functional capacity (402.78 m vs. 390.09 m, P<0.001), preoperative anxiety status (9% vs. 28%, P<0.001), time to first ambulation[25.0(8.0) hours vs. 28.0(12.4) hours, P=0.008], time to first flatus [39.0(22.0) hours vs. 47.7(34.0) hours, P=0.006], duration of the postoperative length of hospital stay [8.0(3.0) days vs. 10.0(5.0) days, P=0.007), and quality of life in terms of psychological dimensions at 1 month postoperatively [53.0(8.0) vs. 49.0(5.0), P<0.001]. Conclusion The short-term, hospital-based, supervised multimodal prehabilitation is feasible with a high degree of compliance in older CRC patients, which improves their short-term clinical outcomes.
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Affiliation(s)
- Xiayun Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China.,College of Medicine, Tongji University, Shanghai, China
| | - Ruizhe Chen
- College of Medicine, Tongji University, Shanghai, China
| | - Lili Ge
- College of Medicine, Tongji University, Shanghai, China
| | - Yifan Gu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Lin Zhang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Li Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Chengle Zhuang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Qian Wu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
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5
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Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2022; 5:CD013259. [PMID: 35588252 PMCID: PMC9118366 DOI: 10.1002/14651858.cd013259.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes. OBJECTIVES To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible. MAIN RESULTS We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. Prehabilitation may also result in fewer complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250) and fewer emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250). The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. On the other hand, prehabilitation may also result in a higher re-admission rate (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250). The certainty of evidence was again low due to downgrading for risk of bias and imprecision. The effect on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies. AUTHORS' CONCLUSIONS Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. Complication rates and the number of emergency department visits postoperatively may also diminish due to a prehabilitation programme, while the number of re-admissions may be higher in the prehabilitation group. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.
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Affiliation(s)
| | | | | | - Rudi Mh Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
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6
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Advocating for prehabilitation for patients undergoing gynecology-oncology surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1875-1881. [DOI: 10.1016/j.ejso.2022.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/03/2022] [Accepted: 04/25/2022] [Indexed: 12/18/2022]
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7
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Drost JM, Cook CB, Spangehl MJ, Probst NE, Mi L, Trentman TL. A Plant-Based Dietary Intervention for Preoperative Glucose Optimization in Diabetic Patients Undergoing Total Joint Arthroplasty. Am J Lifestyle Med 2022; 16:150-154. [PMID: 35185437 PMCID: PMC8848119 DOI: 10.1177/1559827619879073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Purpose. The purpose of this study was to assess the feasibility and effectiveness of a whole food plant-based diet (WFPBD) to improve day of surgery fasting blood glucose (FBG) among patients with type 2 diabetes (T2D). Patients and Methods. Ten patients with T2D scheduled for a total hip or total knee replacement were recruited. For 3 weeks preceding their surgeries, subjects were asked to consume an entirely WFPBD. Frozen WFPBD meals were professionally prepared and delivered to each participant for the 3 weeks prior to surgery. FBG was reassessed on the morning of surgery and compared with preintervention values. Compliance with the diet was assessed. Results. Mean age of subjects and reported duration of diabetes was 65 and 8 years, respectively, average hemoglobin A1c (HbA1c) was 6.6%, and 6 were women. Mean FBG decreased from 127 to 116 mg/dL (P = .2). Five of the subjects experienced improvement in glycemic control, with an average decline of 11 mg/dL. Conclusion. A WFPBD is a potentially effective intervention to improve glycemic control among patients with T2D during the period leading up to surgery. Future controlled trials on a larger sample of patients to assess the impact of a WFPBD on glycemic control and surgical outcomes are warranted.
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Affiliation(s)
- Jennifer M. Drost
- Jennifer M. Drost, MS, PA-C, Department of Anesthesiology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054; e-mail:
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Santa Mina D, Sellers D, Au D, Alibhai SMH, Clarke H, Cuthbertson BH, Darling G, El Danab A, Govindarajan A, Ladha K, Matthew AG, McCluskey S, Ng KA, Quereshy F, Karkouti K, Randall IM. A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations. Front Oncol 2021; 11:629207. [PMID: 33777780 PMCID: PMC7987917 DOI: 10.3389/fonc.2021.629207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies. Methods This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced. Conclusion This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.
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Affiliation(s)
- Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Daniel Sellers
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Darren Au
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gail Darling
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Alaa El Danab
- Clinical Nutrition, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Anand Govindarajan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sinai Health System, Toronto, ON, Canada
| | - Karim Ladha
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew G Matthew
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Stuart McCluskey
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Karen A Ng
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Geriatrics, Sinai Health System, Toronto, ON, Canada
| | - Fayez Quereshy
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Keyvan Karkouti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Ian M Randall
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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9
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The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review. Eur J Anaesthesiol 2020; 36:889-903. [PMID: 31453818 DOI: 10.1097/eja.0000000000001067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.
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10
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The effectiveness pre-operative exercise of muscle strength for early ambulation on lower limb fracture with measurement tool – The Modified Iowa Level of Assistance Scale (MILAS) – in hospital inpatients. ENFERMERIA CLINICA 2020. [DOI: 10.1016/j.enfcli.2019.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Wharton K, Chun Y, Hunsberger J, Jelin E, Garcia A, Stewart D. Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum. J Pediatr Surg 2020; 55:1065-1071. [PMID: 32197827 DOI: 10.1016/j.jpedsurg.2020.02.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/20/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Pectus excavatum is a common chest wall deformity amenable to surgical correction, most commonly by a technique known as the Nuss Procedure. The surgery is associated with significant postoperative pain and lengthy hospital stays. We hypothesized that a standardized enhanced recovery after surgery (ERAS) pathway would result in significantly reduced length of stay (LOS) and reduced levels of postoperative pain without an increase in readmissions or emergency department (ED) visits. METHODS We instituted a pectus excavatum ERAS program at a high-volume academic center. Our ERAS protocol standardized perioperative exercise and pharmacologic regimens, pre- and post-operative education, and early return to activity. We conducted a retrospective review of all patients undergoing the Nuss procedure from 2015 to 2018. ERAS was implemented at the mid-point of the study period, and pre- and post-protocol patients were compared in our analysis. The primary outcome measure was LOS. The secondary outcomes included pain scores, incidence of urinary retention, and readmissions or ED visits. RESULTS One hundred nine patients were included in this study (51 patients pre-ERAS and 58 post-ERAS). The average length of hospitalization prior to implementation of ERAS was 3.49 and after the implementation 2.90 (p = 0.0007). The implementation of ERAS showed a trend of decreasing readmissions and emergency department visits, but this did not reach statistical significance. There was a statistically significant decrease in both requirement for urinary catheter placement and pain scores on postoperative day 0. CONCLUSIONS Implementation of ERAS for the Nuss procedure leads to a significant reduction in LOS, early pain scores, and urinary catheter usage, without an increase in post-operative ED visits and hospital readmissions. An ERAS protocol should be utilized in this patient population. TYPE OF STUDY Retrospective comparative study. TYPE OF EVIDENCE Level III.
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Affiliation(s)
- Kristin Wharton
- Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg Center 7311, Baltimore, MD 21287
| | - Young Chun
- Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg Center 7311, Baltimore, MD 21287
| | - Joann Hunsberger
- Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg Center 6321, Baltimore, MD 21287
| | - Eric Jelin
- Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg Center 7351, Baltimore, MD 21287
| | - Alejandro Garcia
- Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg Center 7335, Baltimore, MD 21287
| | - Dylan Stewart
- Maria Fareri Children's Hospital, New York Medical College, Westchester Medical Center, 100 Woods Road, Taylor E-154, Valhalla, NY 10595.
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12
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Beck A, Vind Thaysen H, Hasselholt Soegaard C, Blaakaer J, Seibaek L. Prehabilitation in cancer care: patients' ability to prepare for major abdominal surgery. Scand J Caring Sci 2020; 35:143-155. [PMID: 32043644 DOI: 10.1111/scs.12828] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients' perspectives on standardised, multimodal prehabilitation programmes showed barriers to adherence. Further investigation of patients' ability to prepare is needed. AIM To investigate what patients with cancer who were due to undergo major abdominal surgery actually were able to do when provided with preoperative, home-based, multimodal recommendations presented in a leaflet. METHODS Patients from the colorectal- or ovarian cancer centre, who were scheduled for major abdominal surgery, received a leaflet with preoperative recommendations. On a daily basis, the patients filled in what they had completed in relation to these recommendations, so that adherence could be investigated. Additionally, face-to-face interviews were conducted to evaluate patients' experiences of using the leaflet. Malterud's principles of systematic text condensation were used to analyse the interviews. A convergent design was used to merge the quantitative and qualitative data into a combined interpretation presented in the discussion. RESULTS A total of 53 patients returned a completed leaflet, and five patients were interviewed. In the combined interpretation, patients' ability to prepare was presented through four major domains. The domains were adherence and the importance of support, manageable actions leading to change, preparation in a broader perspective and impediments to preparation and to symptom relief. CONCLUSIONS Patients prepared themselves in various ways, which were not limited to recommendations inspired by multimodal prehabilitation. Patients from the ovarian cancer centre increased their weekly exercise during the preoperative period, which indicates that the leaflet not only functioned as a data collection tool, but also motivated and supported the patients in prehabilitation-related actions. Patients' perspectives on prehabilitation need to be taken into account, when aiming to enhance patient-centredness and adherence.
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Affiliation(s)
- Anne Beck
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus N, Denmark
| | | | | | - Jan Blaakaer
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Lene Seibaek
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus N, Denmark
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13
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Shibuya M, Nanri Y, Kamiya K, Fukushima K, Uchiyama K, Takahira N, Takaso M, Fukuda M, Matsunaga A. The maximal gait speed is a simple and useful prognostic indicator for functional recovery after total hip arthroplasty. BMC Musculoskelet Disord 2020; 21:84. [PMID: 32033550 PMCID: PMC7007664 DOI: 10.1186/s12891-020-3093-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 01/24/2020] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The present study aimed to compare the capabilities of preoperative usual and maximal gait speeds in predicting functional recovery in patients who have undergone total hip arthroplasty (THA). METHODS Primary and unilateral THAs were performed in 317 patients, and the proportion of patients who achieved unassisted walking (functional recovery) 5 days postoperatively was recorded as an outcome measure. Preoperative functional assessment included hip pain, leg muscle strength, range of motion (ROM), and gait speed evaluations. The capabilities of preoperative usual and maximal gait speeds in predicting functional recovery were compared based on the areas under the curves (AUCs) of receiver operating characteristic (ROC) curves. Further, ROC curves were constructed using two models: 1. a model of gait speed only and 2. a clinical model including age, sex, leg muscle strength, and ROM. RESULTS On the AUCs for predictive ability of functional recovery, maximal gait speed was greater than usual gait speed (0.66 and 0.70, respectively). The AUC for maximal gait speed was as large as that of the clinical model (0.70 and 0.70, respectively). CONCLUSION Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA.
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Affiliation(s)
- Manaka Shibuya
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Yuta Nanri
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan. .,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Naonobu Takahira
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Michinari Fukuda
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
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Molenaar CJL, Papen-Botterhuis NE, Herrle F, Slooter GD. Prehabilitation, making patients fit for surgery - a new frontier in perioperative care. Innov Surg Sci 2019; 4:132-138. [PMID: 33977122 PMCID: PMC8059351 DOI: 10.1515/iss-2019-0017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023] Open
Abstract
Optimizing a patients’ condition before surgery to improve the postoperative outcome can be achieved by using prehabilitation; preoperative interventions focusing on modifiable risk factors to improve the physical, nutritional, and mental status of the patient. A multimodal, multidisciplinary approach induces a synergistic effect between the various interventions and affects the outcome postoperatively. While awaiting higher-quality evidence, the worldwide implementation of prehabilitation programs has started, resulting in a true revolution in perioperative care.
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Affiliation(s)
| | | | - Florian Herrle
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Gerrit D Slooter
- Department of Surgical Oncology, Máxima MC, 5500MB, Veldhoven, the Netherlands, E-mail:
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Delayed recovery following thoracic surgery: persistent issues and potential interventions. Curr Opin Anaesthesiol 2019; 32:3-9. [PMID: 30507683 DOI: 10.1097/aco.0000000000000669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges. RECENT FINDINGS Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes. SUMMARY Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.
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