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Huang Y, Wang K, Wei X, Fang Q. ASO Author Reflections: Application and Prospect of Patient-Reported Outcomes in Enhanced Recovery After Esophagectomy for Cancer. Ann Surg Oncol 2024; 31:5770-5771. [PMID: 38839669 DOI: 10.1245/s10434-024-15578-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Yixuan Huang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Kangning Wang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Xing Wei
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Qiang Fang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China.
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Jolly S, Paliwal S, Gadepalli A, Chaudhary S, Bhagat H, Avitsian R. Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review. J Neurosurg Anesthesiol 2024; 36:201-210. [PMID: 38011868 DOI: 10.1097/ana.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.
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Affiliation(s)
- Sagar Jolly
- Department of General Anesthesiology, Cleveland Clinic, OH
| | | | - Aditya Gadepalli
- Department of Anaesthetics and Intensive Care, Royal Free London NHS Foundation Trust, London, UK
| | - Sheena Chaudhary
- Department of Neuroanesthesia and Critical Care, Fortis Memorial Research Institute, Gurugram, HR, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, OH
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Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open 2024; 7:e2417310. [PMID: 38888922 PMCID: PMC11195621 DOI: 10.1001/jamanetworkopen.2024.17310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/20/2024] Open
Abstract
Importance A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. Objective To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. Data Sources MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Study Selection Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data Extraction and Synthesis Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. Main Outcome and Measures The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Results Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. Conclusions and Relevance In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.
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Affiliation(s)
- Khara M. Sauro
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology and Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christine Smith
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seremi Ibadin
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abigail Thomas
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Linda Bakunda
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bishnu Bajgain
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven P. Bisch
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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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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Dong J, Lei Y, Wan Y, Dong P, Wang Y, Liu K, Zhang X. Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis. Updates Surg 2024:10.1007/s13304-024-01764-z. [PMID: 38446378 DOI: 10.1007/s13304-024-01764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/22/2024] [Indexed: 03/07/2024]
Abstract
Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.
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Affiliation(s)
- Jingyu Dong
- Department of Anesthesiology, The Second Hospital & Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, China
| | - Yuqiong Lei
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, China
| | - Yantong Wan
- Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Peng Dong
- College of Anesthesiology, Southern Medical University, Guangzhou, China
| | - Yingbin Wang
- Department of Anesthesiology, The Second Hospital & Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China
| | - Kexuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, China.
| | - Xiyang Zhang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, China.
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Qin X, Li H, Long J, Feng C. A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1283-1291. [PMID: 38212410 DOI: 10.1007/s00586-023-08105-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis. METHODS According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria. RESULTS Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24). CONCLUSIONS The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.
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Affiliation(s)
- Xia Qin
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Huaxi Li
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Jiang Long
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Chencheng Feng
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China.
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Magableh HM, Ibrahim S, Pennington Z, Nathani KR, Johnson SE, Katsos K, Freedman BA, Bydon M. Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients. Neurosurgery 2024:00006123-990000000-01058. [PMID: 38358272 DOI: 10.1227/neu.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.
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Affiliation(s)
- Hamzah M Magableh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sufyan Ibrahim
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Konstantinos Katsos
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Yu B, Xiao Y, Dai H, Yu Y, Lin Y, Xu J. Spinal intradural extramedullary tumors: microscopic keyhole resection with the focus on intraoperative neurophysiological monitoring and long-term outcome. J Orthop Surg Res 2023; 18:598. [PMID: 37574567 PMCID: PMC10424432 DOI: 10.1186/s13018-023-04074-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVE Spinal schwannomas (SS) and spinal meningiomas (SM) account for most intradural extramedullary (IDEM) tumors. These tumors are usually benign lesions, which generally respond favorably to surgical excision. Few studies up to now tried to determine the long-term outcome after minimally invasive surgery (MIS) with multimodal intraoperative neurophysiological monitoring (IONM) for IDEM tumors. The aim of this study was to present one of the largest case series with special regard to IONM findings and long-term outcome after MIS-keyhole surgery with a tubular retractor system. METHODS Between January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients' medical files were retrospectively analyzed. RESULTS Surgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom's criteria. CONCLUSION MIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.
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Affiliation(s)
- Bofei Yu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Yuhua Xiao
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Hanhao Dai
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Yunlong Yu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Yuan Lin
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China
| | - Jie Xu
- Division of Spine Surgery and Electrophysiological Center, Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, No. 134, East Street, Fuzhou, 350001, Fujian, China.
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Wu J, Gao L, Shi Q, Qin C, Xu K, Jiang Z, Zhang X, Li M, Qiu J, Gu W. Accuracy Evaluation Trial of Mixed Reality-Guided Spinal Puncture Technology. Ther Clin Risk Manag 2023; 19:599-609. [PMID: 37484696 PMCID: PMC10361284 DOI: 10.2147/tcrm.s416918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To evaluate the accuracy of mixed reality (MR)-guided visualization technology for spinal puncture (MRsp). Methods MRsp involved the following three steps: 1. Lumbar spine computed tomography (CT) data were obtained to reconstruct virtual 3D images, which were imported into a HoloLens (2nd gen). 2. The patented MR system quickly recognized the spatial orientation and superimposed the virtual image over the real spine in the HoloLens. 3. The operator performed the spinal puncture with structural information provided by the virtual image. A posture fixation cushion was used to keep the subjects' lateral decubitus position consistent. 12 subjects were recruited to verify the setup error and the registration error. The setup error was calculated using the first two CT scans and measuring the displacement of two location markers. The projection points of the upper edge of the L3 spinous process (L3↑), the lower edge of the L3 spinous process (L3↓), and the lower edge of the L4 spinous process (L4↓) in the virtual image were positioned and marked on the skin as the registration markers. A third CT scan was performed to determine the registration error by measuring the displacement between the three registration markers and the corresponding real spinous process edges. Results The setup errors in the position of the cranial location marker between CT scans along the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) axes of the CT bed measured 0.09 ± 0.06 cm, 0.30 ± 0.28 cm, and 0.22 ± 0.12 cm, respectively, while those of the position of the caudal location marker measured 0.08 ± 0.06 cm, 0.29 ± 0.18 cm, and 0.18 ± 0.10 cm, respectively. The registration errors between the three registration markers and the subject's real L3↑, L3↓, and L4↓ were 0.11 ± 0.09 cm, 0.15 ± 0.13 cm, and 0.13 ± 0.10 cm, respectively, in the SI direction. Conclusion This MR-guided visualization technology for spinal puncture can accurately and quickly superimpose the reconstructed 3D CT images over a real human spine.
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Affiliation(s)
- Jiajun Wu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
| | - Lei Gao
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
| | - Qiao Shi
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital of China, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, People’s Republic of China
| | - Chunhui Qin
- Department of Pain Management, Yueyang Integrated Traditional Chinese Medicine and Western Medicine Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, People’s Republic of China
| | - Kai Xu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
| | - Zhaoshun Jiang
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
| | - Xixue Zhang
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
| | - Ming Li
- Department of Radiology, Huadong Hospital affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
| | - Jianjian Qiu
- Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
| | - Weidong Gu
- Department of Anesthesiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People’s Republic of China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, 200040, People’s Republic of China
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Lei M, Zheng W, Cao Y, Cao X, Shi X, Su X, Liu Y. Treatment of patients with metastatic epidural spinal cord compression using an enhanced recovery after surgery program. Front Cell Dev Biol 2023; 11:1183913. [PMID: 37250907 PMCID: PMC10213636 DOI: 10.3389/fcell.2023.1183913] [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: 03/10/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose: The aims of this study were to introduce a new medical, pathway based on the concept of "enhanced recovery after surgery" (ERAS) for patients with metastatic epidural spinal cord compression (MESCC), and to test whether the ERAS program could improve clinical metrics among such patients. Methods: Data from patients with MESCC (n = 98), collected between December 2016 and December 2019 (Non-ERAS cohort), and from 86 patients with metastatic epidural spinal cord compression collected between January 2020 and December 2022 (ERAS cohort), were retrospectively analyzed. Patients were treated by decompressive surgery combined with transpedicular screw implantation and internal fixation. Patient baseline clinical characteristics were collected and compared between the two cohorts. Surgical outcomes analyzed included operation time; intraoperative blood loss; postoperative length of hospital stay; time to ambulation, regular diet, urinary catheter removal, and radiation therapy; perioperative complications; anxiety; depression; and satisfaction with treatment. Results: No significant differences in clinical characteristics were found between the non-ERAS and enhanced recovery after surgery cohorts (all p > 0.050), indicating that the two cohorts were comparable. Regarding surgical outcomes, the enhanced recovery after surgery cohort had significantly less intraoperative blood loss (p < 0.001); shorter length of postoperative hospital stay (p < 0.001); shorter time to ambulation (p < 0.001), regular diet (p < 0.001), urinary catheter removal (p < 0.001), radiation administration (p < 0.001), and systemic internal therapy (p < 0.001); lower perioperative complication rate (p = 0.024); less postoperative anxiety (p = 0.041); and higher score for satisfaction with treatment (p < 0.001); whereas operation time (p = 0.524) and postoperative depression (p = 0.415) were similar between the two cohorts. Compliance analysis demonstrated that ERAS interventions were successfully conducted in the vast majority of patients. Conclusion: The enhanced recovery after surgery intervention is beneficial to patients with metastatic epidural spinal cord compression, according to data on intraoperative blood loss; length of hospital stay; time to ambulation, regular diet, urinary catheter removal, radiation exposure, and systemic internal therapy; perioperative complication; alleviation of anxiety; and improvement of satisfaction. However, clinical trials to investigate the effect of enhanced recovery after surgery are needed in the future.
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Affiliation(s)
- Mingxing Lei
- Senior Department of Orthopedic Surgery, The Fourth Medical Center of PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Hainan Hospital of PLA General Hospital, Beijing, China
| | - Wenjing Zheng
- Department of Chemical Poisoning Treatment, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yuncen Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xuyong Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiuyun Su
- Intelligent Medical Innovation institute, Southern University of Science and Technology Hospital, Shenzhen, China
| | - Yaosheng Liu
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, PLA General Hospital, Beijing, China
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Liu B, Liu S, Wang B, Liu W, Chen L, Zheng T, Lu D, Ma T, He S. Effectiveness and safety of implementing an enhanced patient comfort programme for elective neurosurgical patients: a randomised controlled trial protocol. BMJ Open 2023; 13:e063534. [PMID: 37072357 PMCID: PMC10124223 DOI: 10.1136/bmjopen-2022-063534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Patient comfort is an important quality indicator of healthcare. According to Kolcaba's comfort theory, enhanced comfort is achieved by meeting the needs in four contexts: physical, psychospiritual, sociocultural and environmental. An enhanced patient comfort (EPC) programme based on this theory has been designed for elective neurosurgical patients. This study aims to assess its feasibility, effectiveness and safety. METHODS AND ANALYSIS The EPC programme patients will be evaluated in a single institutional randomised controlled trial. A total of 110 patients admitted for elective neurosurgery (including craniotomy, endoscopic trans-sphenoidal surgery and spine surgery) will be randomised in a 1:1 ratio to two groups. Patients in the EPC group are managed under the newly developed EPC programme, which aims to enhance patient experience and includes care coordination since admission (such as appointment of a care support coordinator, personalised setting, and cultural and spiritual support), preoperative management (such as lifestyle intervention, potential psychological and sleep intervention, and prerehabilitation), intraoperative and anaesthetic management (such as nurse coaching, music playing, and pre-emptive warming), postoperative management (such as early extubation, early diet advancement, mood and sleep management, and early ambulation) and optimised discharge planning; while those in the control group receive conventional perioperative care. The primary outcome is patient satisfaction and comfort measured by the Chinese Surgical Inpatient Satisfaction and Comfort Questionnaire. The secondary outcomes include postoperative morbidity and mortality, postoperative pain score, postoperative nausea and vomiting, functional recovery status (Karnofsky performance status and Quality of Recovery-15 score), mental status (anxiety and depression), nutritional status, health-related quality of life, hospital length of stay, reoperation and readmission rates, overall cost and patient experience. ETHICS AND DISSEMINATION Ethical approval to conduct the study has been obtained from Institutional Review Board of Xi'an International Medical Center (No. 202028). The results will be presented at scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER Chinese clinical trial registry ChiCTR2000039983.
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Affiliation(s)
- Bolin Liu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Shujuan Liu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Binrong Wang
- Department of Anesthesiology, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Wenjuan Liu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Lei Chen
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Tao Zheng
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Dan Lu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Tao Ma
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
| | - Shiming He
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, Shaanxi Province, China
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Chakravarthy VB, Laufer I, Amin AG, Cohen MA, Reiner AS, Vuong C, Persaud PS, Ruppert LM, Puttanniah VG, Afonso AM, Tsui VS, Brallier JW, Malhotra VT, Bilsky MH, Barzilai O. Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors. Cancer 2022; 128:4109-4118. [PMID: 36219485 PMCID: PMC10859187 DOI: 10.1002/cncr.34484] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. METHODS The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]). RESULTS A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). CONCLUSIONS The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.
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Affiliation(s)
- Vikram B. Chakravarthy
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Neurological Surgery, New York University Medical Center, New York, New York, USA
| | - Anubhav G. Amin
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A. Cohen
- Surgery (Head and Neck), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cindy Vuong
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Petal‐Ann S. Persaud
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M. Ruppert
- Rehabilitation Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay G. Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Van S. Tsui
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jess W. Brallier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek T. Malhotra
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H. Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Zhang Y, Yue H, Qin Y, Wang J, Zhao C, Cheng M, Han B, Han R, Cui W. Effect of Sufentanil Combined with Gabapentin on Acute Postoperative Pain in Patients Undergoing Intraspinal Tumor Resection: Study Protocol for a Randomized Controlled Trial. J Pain Res 2022; 15:2619-2628. [PMID: 36072908 PMCID: PMC9444033 DOI: 10.2147/jpr.s374898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients undergoing intraspinal tumor resection usually experience severe postoperative pain. Inadequate postoperative analgesia usually leads to severe postsurgical pain, which could cause patients to suffer from many other related complications. Recently, an increasing number of studies have found that gabapentin can relieve hyperalgesia, postoperative pain, and postoperative inflammation. However, there have been no reports on the use of gabapentin combined with sufentanil preoperatively for acute pain following intraspinal tumor resection. Study Design and Methods This is a protocol for a randomized, placebo-controlled, and double-blinded trial. One-hundred and sixty-eight participants with chronic pain related to the intraspinal tumor will be randomized into the gabapentin and placebo groups in a 1:1 ratio. In the gabapentin group, patients will be given 300 mg gabapentin orally 36 h, 24 h, and 12 h before surgery; the placebo group will receive a placebo orally at the same time points preoperatively. To estimate the efficacy and safety endpoints, all the researchers and patients will be blinded until the completion of this study. The primary outcome will be the consumption of sufentanil within 48 h postoperatively. The secondary outcomes include the visual analog scale pain score and Von Frey mechanical pain threshold 36 h and 24 h before and 24 h and 48 h after surgery, the incidence of postoperative nausea, vomiting, and drowsiness, the length of hospital stay and medical expenses. Discussion This trial is to evaluate the efficacy and safety of gabapentin combined with sufentanil for postoperative analgesia in patients who complain of pain before intraspinal tumor resection. The findings will provide a new strategy for multimode perioperative analgesia management in these patients.
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Affiliation(s)
- Yuan Zhang
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongli Yue
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yirui Qin
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiajing Wang
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chenyang Zhao
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Miao Cheng
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Bo Han
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Ruquan Han; Weihua Cui, Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, No. 119, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +8613701285393; Tel +8613701285393, Fax +861059976658, Email ;
| | - Weihua Cui
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Liu B, Liu S, Zheng T, Lu D, Chen L, Ma T, Wang Y, Gao G, He S. Neurosurgical enhanced recovery after surgery ERAS for geriatric patients undergoing elective craniotomy: A review. Medicine (Baltimore) 2022; 101:e30043. [PMID: 35984154 PMCID: PMC9388027 DOI: 10.1097/md.0000000000030043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Population aging is an unprecedented, multifactorial, and global process that poses significant challenges to healthcare systems. Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care. The first neurosurgical ERAS protocol for elective craniotomy has contributed to a shortened postoperative hospital stay, accelerated functional recovery, improved patient satisfaction, and reduced medical care cost in adult patients aged 18 to 65 years compared with conventional perioperative care. However, ERAS protocols for geriatric patients over 65 years of age undergoing cranial surgery are lacking. In this paper, we propose a novel ERAS protocol for such patients by reviewing and summarizing the key elements of successful ERAS protocols/guidelines and optimal perioperative care for geriatric patients described in the literature, as well as our experience in applying the first neurosurgical ERAS protocol for a quality improvement initiative. This proposal aimed to establish an applicable protocol for geriatric patients undergoing elective craniotomy, with evidence addressing its feasibility, safety, and potential efficacy. This multimodal, multidisciplinary, and evidence-based ERAS protocol includes preoperative, intraoperative, and postoperative assessment and management as well as outcome measures. The implementation of the current protocol may hold promise in reducing perioperative morbidity, enhancing functional recovery, improving postoperative outcomes in geriatric patients scheduled for elective craniotomy, and serving as a stepping stone to promote further research into the advancement of geriatric patient care.
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Affiliation(s)
- Bolin Liu
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Shujuan Liu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Tao Zheng
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Dan Lu
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Lei Chen
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Tao Ma
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Shiming He
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Shiming He, Department of Neurosurgery, Xi’an International Medical Center, No. 777 Xitai Road, Xi’an 710100, China (e-mail: ; )
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Abstract
Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.
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Licina DA, Silvers DA. Perioperative Multimodal Analgesia for Adults undergoing surgery of the Spine- Systematic Review and Meta-analysis of Three or More Modalities. World Neurosurg 2022; 163:11-23. [PMID: 35346882 DOI: 10.1016/j.wneu.2022.03.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Multimodal analgesia is a strategy which may be employed to improve pain management in the perioperative period in patients undergoing surgery of the spine. However, there is no review evidence available on quantitative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the impact of maximal (three or more analgesic agents) multimodal analgesic medication in patients undergoing surgery of the spine. METHODS We included randomized controlled trials (RCT's) evaluating the use of three or more multimodal analgesia components (maximal multi modal analgesia) in patients undergoing spinal surgery. We excluded patients receiving neuraxial or regional analgesia. The control group consisted of placebo, standard care (any therapeutic modality including two or less analgesic components). Primary outcomes were post-operative pain scores at rest, at twenty-four, and forty eight hours. We searched the MEDLINE via Ovid SP; EMBASE via Ovid SP; and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used Cochrane's standard methods. RESULTS We identified consistently improved analgesic endpoints across all pre-determined primary and secondary outcomes. A total of eleven eligible studies evaluated the primary outcome of pain at rest at twenty four hours. Patients receiving maximal multimodal analgesia were identified to have lower pain scores with an average of MD [-1.03], p<0.00001. Length of hospital stay was decreased in patients receiving multimodal analgesia MD [-0.55], p<0.00001. CONCLUSION Perioperative maximal multimodal analgesia consistently improves visual analogue scale outcomes in adult population in the immediate post-operative period, with a moderate quality of evidence. There is significant decrease in hospital length of stay in patients receiving maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.
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Chau JPC, Liu X, Lo SHS, Chien WT, Hui SK, Choi KC, Zhao J. Perioperative enhanced recovery programmes for women with gynaecological cancers. Cochrane Database Syst Rev 2022; 3:CD008239. [PMID: 35289396 PMCID: PMC8922407 DOI: 10.1002/14651858.cd008239.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015. OBJECTIVES To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes. SEARCH METHODS We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty. MAIN RESULTS We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.
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Affiliation(s)
- Janita Pak Chun Chau
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xu Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sze Ki Hui
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jie Zhao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Langnas EM, Matthay ZA, Lin A, Harbell MW, Croci R, Rodriguez-Monguio R, Chen CL. Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis. Perioper Med (Lond) 2021; 10:38. [PMID: 34775985 PMCID: PMC8591895 DOI: 10.1186/s13741-021-00209-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/18/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear. STUDY DESIGN We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends. RESULTS Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01). CONCLUSION Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.
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Affiliation(s)
- E M Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.
| | - Z A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, USA
| | - A Lin
- UCSF School of Medicine, University of California, San Francisco, San Francisco, USA
| | - M W Harbell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - R Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, USA
| | - R Rodriguez-Monguio
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, USA.,Medication Outcomes Center, University of California, San Francisco, San Francisco, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
| | - C L Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
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Jin MC, Ho AL, Feng AY, Zhang Y, Staartjes VE, Stienen MN, Han SS, Veeravagu A, Ratliff JK, Desai AM. Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection. Spine J 2021; 21:1687-1699. [PMID: 33065272 DOI: 10.1016/j.spinee.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/05/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection. METHODS The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%. RESULTS A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients. CONCLUSIONS We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Clinical Neuroscience Center, University Hospital Zurich, Switzerland; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Summer S Han
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.
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Agarwal P, Frid I, Singer J, Zalatimo O, Schirmer CM, Kimmell KT, Agarwal N. Neurosurgery perception of Enhanced Recovery After Surgery (ERAS) protocols. J Clin Neurosci 2021; 92:110-114. [PMID: 34509236 DOI: 10.1016/j.jocn.2021.07.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/08/2021] [Accepted: 07/25/2021] [Indexed: 12/19/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are widespread in several fields, particularly general surgery, and attempt to deliver surgical care at a lower cost while also improving patient outcomes. However, few institutions have implemented ERAS protocols in neurosurgery. As such, a survey of neurosurgeons on the current state of ERAS in neurosurgery was conducted to provide insight on scaling the practice nationally. A 15-question survey was designed to assess the implementation of andsatisfaction with ERAS protocols at individual institutions. A total of 39 responses were collected from 38 unique institutions. 58.9%(N = 23) reported implementation of neurosurgical ERAS protocols. 52.1% (N = 12) of the responses were neurosurgeons at academic institutions withneurosurgical residency programs. Most neurosurgeons used ERAS protocolsfor spine cases (N = 23), with only 17.3% (N = 4) employing ERAS protocolsfor cranial cases. 69.5% (N = 16) of survey participants reported that thedesign and implementation of ERAS was a multidisciplinary effort acrossmany departments, including neurosurgery, anesthesia, and pharmacy.Decreased costs and intensive care unit (ICU) admission were reported tobe unanticipated benefits of ERAS implementation. Unanticipated challenges to implementation of new protocols included difficulties withelectronic medical record (EMR) integration, agreement of protocoldetails amongst stakeholders, uniform implementation of protocols by allneurosurgeons, and lack of adaptability by multidisciplinary staff. Meandepartment satisfaction with ERAS protocol implementation was 4.00 +/- 0.81 (N = 22) on a 5-point Likert scale.
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Affiliation(s)
- Prateek Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States
| | - Ilya Frid
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States
| | - Justin Singer
- Spectrum Health Medical Group, Department of Neurosurgery, Grand Rapids, MI, United States
| | - Omar Zalatimo
- Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States; Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Kristopher T Kimmell
- Rochester Regional Health, Department of Neurosurgery, Rochester, NY, United States
| | - Nitin Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States.
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21
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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Curley KL, Richards AE, Zhang N, Lyons MK, Neal MT. Enhanced recovery after posterior cervical fusion surgery: A retrospective case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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23
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The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3755-3762. [PMID: 34398335 DOI: 10.1007/s00586-021-06960-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/29/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.
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Patel J, Pennington Z, Hersh AM, Hung B, Schilling A, Antar A, Elsamadicy AA, de la Garza Ramos R, Lubelski D, Larry Lo SF, Sciubba DM. Drivers of Readmission and Reoperation After Surgery for Vertebral Column Metastases. World Neurosurg 2021; 154:e806-e814. [PMID: 34389529 DOI: 10.1016/j.wneu.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine those clinical, demographic, and operative factors that predict 30-day unplanned reoperation and readmission within a population of adults who underwent spinal metastasis surgery at a comprehensive cancer center. METHODS Adults who underwent spinal metastasis surgery at a comprehensive cancer center were analyzed. Data included baseline laboratory values, cancer history, demographics, operative characteristics and medical comorbidities. Medical comorbidities were quantified using the modified Charlson Comorbidity Index (CCI). Values associated with the outcomes of interest were then subjected to multivariable logistic regression to identify independent predictors of readmission and reoperation. RESULTS A total of 345 cases were identified. Mean age was 59.4 ± 11.7 years, 56% were male, and the racial makeup was 64% white, 29% black, and 7.3% other. Forty-two patients (12.2%) had unplanned readmissions, most commonly for wound infection with dehiscence (14.2%), venous thromboembolism (14.2%), and bowel obstruction/complication (11.9%). Thirteen patients required reoperation (4%), most commonly for wound infection with dehiscence (39%) or local recurrence (23%). Multivariable analysis showed that the modified CCI (odds ratio [OR], 1.25; 95% confidence interval [CI] 1.03-1.52; P = 0.03) was an independent predictor of 30-day readmission. Independent predictors of 30-day unplanned reoperation were: black (vs. white) race (OR, 0.08; 95% CI, 0.01-0.41; P < 0.01), length of stay (OR, 1.05 per day; 95% CI, 1.00-1.09; P = 0.04), and CCI (OR, 1.72 per point; 95% CI, 1.29-2.28; P < 0.01). CONCLUSIONS Increasing medical comorbidities is independently predictive of both 30-day unplanned readmission and reoperation after spinal metastasis surgery. Unplanned reoperation is also positively predicted by a longer index admission. Neither tumor pathology nor age predicted outcome, suggesting that poor wound-healing factors and increased surgical morbidity may best predict these adverse outcomes.
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Affiliation(s)
- Jaimin Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bethany Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Schilling
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert Antar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA.
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25
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Zaed I, Bossi B, Ganau M, Tinterri B, Giordano M, Chibbaro S. Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: A systematic review of the literature. Neurochirurgie 2021; 68:61-68. [PMID: 33901525 DOI: 10.1016/j.neuchi.2021.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 03/07/2021] [Accepted: 04/11/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Recent years have been characterized by a great technological and clinical development in spine surgery. In particular, enhanced recovery after surgery (ERAS) programs, started to gain interest also in this surgical field. Here we tried to analyse the current state of art of ERAS technique in spine surgery. MATERIAL AND METHOD A systematic review of the literature has been performed in order to find all the possible inclusions. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, Medline databases was conducted to identify all full-text articles in the English-language literature describing the use of ERAS programs or techniques for spine surgery in adult patients. RESULTS Out of the 827 studies found, only 21 met the inclusion criteria has been retained to be included in the present study. The most frequently benefits of ERAS protocols were shorter hospitalisations (n=15), and decreased complication rates (n=8) lower postoperative pain scores (n=4). These benefits were seen in the 3 main categories considered: lumbar spine surgeries, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine. CONCLUSION There are an arising amount of data showing that the use of ERAS programs could be helpful in reducing the days of hospitalizations and the number of complications for certain spinal procedures and in a highly selected group of patients. Despite the large interest on the topic; there is an important lack of high level of scientific evidences. Because of that, there is the need to encourage the design and creation of new randomized clinical trials that will validate the present findings.
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Affiliation(s)
- I Zaed
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy; Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano (MI), Italy.
| | - B Bossi
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy
| | - M Ganau
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - B Tinterri
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy
| | - M Giordano
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - S Chibbaro
- Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
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Young R, Cottrill E, Pennington Z, Ehresman J, Ahmed AK, Kim T, Jiang B, Lubelski D, Zhu AM, Wright KS, Gavin D, Russo A, Hanna MN, Bydon A, Witham TF, Zygourakis C, Theodore N. Experience with an Enhanced Recovery After Spine Surgery protocol at an academic community hospital. J Neurosurg Spine 2021; 34:680-687. [PMID: 33361481 DOI: 10.3171/2020.7.spine20358] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital. METHODS A multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled patients to a historic cohort of age- and procedure-matched controls. The primary study outcomes were quantity of opiate use in morphine milligram equivalents (MMEs) on postoperative day (POD) 1 and length of stay. Secondary outcomes included frequency and duration of indwelling urinary catheter use, discharge disposition, 30-day readmission and reoperation rates, and complication rates. Multivariable linear regression was used to determine whether ERASS protocol use was independently predictive of opiate use on POD 1. RESULTS In total, 97 patients were included in the study cohort and were compared with a historic cohort of 146 patients. The patients in the ERASS group had lower POD 1 opiate use than the control group (26 ± 33 vs 42 ± 40 MMEs, p < 0.001), driven largely by differences in opiate-naive patients (16 ± 21 vs 38 ± 36 MMEs, p < 0.001). Additionally, patients in the ERASS group had shorter hospitalizations than patients in the control group (51 ± 30 vs 62 ± 49 hours, p = 0.047). On multivariable regression, implementation of the ERASS protocol was independently predictive of lower POD 1 opiate consumption (β = -7.32, p < 0.001). There were no significant differences in any of the secondary outcomes. CONCLUSIONS The authors found that the development and implementation of a comprehensive ERASS protocol led to a modest reduction in postoperative opiate consumption and hospital length of stay in patients undergoing elective cervical or lumbar procedures. As suggested by these results and those of other groups, the implementation of ERASS protocols may reduce care costs and improve patient outcomes after spine surgery.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Donna Gavin
- 3Neuroscience Administration, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; and
| | - Alyson Russo
- 4Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Marie N Hanna
- 4Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine
| | | | | | - Corinna Zygourakis
- 5Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California
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27
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Li ZE, Lu SB, Kong C, Sun WZ, Wang P, Zhang ST. Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study. BMC Musculoskelet Disord 2021; 22:283. [PMID: 33731057 PMCID: PMC7968191 DOI: 10.1186/s12891-021-04166-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care. Methods During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected. Result A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%. Conclusions Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.
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Affiliation(s)
- Zhong-En Li
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Shi-Bao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China. .,National Clinical Research Center for Geriatric Diseases, Beijing, China.
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Wen-Zhi Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Si-Tao Zhang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China
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28
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Ntalouka MP, Brotis AG, Bareka MV, Stertsou ES, Fountas KN, Arnaoutoglou EM. Multimodal Analgesia in Spine Surgery: An Umbrella Review. World Neurosurg 2021; 149:129-139. [PMID: 33610874 DOI: 10.1016/j.wneu.2021.02.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE In recent years, there has been a growing interest regarding the implementation of multimodal analgesia as an important component of the ideal perioperative patient management. The aim of the current umbrella review was to establish the role of multimodal analgesia in patients undergoing spine surgery during the immediate postoperative period. METHODS A systematic review of the pertinent literature was performed. The evaluation was based on a multitude of primary endpoints including the postoperative requirements for patient-controlled analgesia, pain intensity, back-related disability, overall functionality, patient satisfaction, complications, length of hospitalization, and costs. RESULTS The results were summarized using a meta-analysis in the presence of quantitative data or in a narrative review, otherwise. There was a large body of high-quality evidence supporting that the implementation of multimodal analgesia improves patient outcome in terms of the intensity of postoperative pain, the requirements for postoperative opioid analgesia, and the opioid-associated side effects. Similarly, limited high-quality evidence supported that multimodal analgesia improved patients' functionality and satisfaction while decreasing the length of hospitalization and overall costs of surgery. However, the results were inconclusive as far as the disability was concerned. CONCLUSIONS Multimodal analgesia seems to have an essential role for the optimal management of patients undergoing spine surgery. Future research is required to optimize the multimodal analgesia protocols in this group of patients.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece.
| | - Alexandros G Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Larissa, Greece
| | - Metaxia V Bareka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Eleonora S Stertsou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Kostantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Eleni M Arnaoutoglou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
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29
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Pennington Z, Cottrill E, Lubelski D, Ehresman J, Theodore N, Sciubba DM. Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery. J Neurosurg Spine 2021; 34:325-347. [PMID: 33157522 DOI: 10.3171/2020.6.spine20795] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. METHODS Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. RESULTS Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. CONCLUSIONS Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.
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