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Mounir MM, Fahim MI. Role of Enhanced Recovery Program for Colorectal Cancer Patients: National Cancer Institute Experience. Indian J Surg Oncol 2021; 12:218-221. [PMID: 33814856 DOI: 10.1007/s13193-021-01278-9] [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: 01/30/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022] Open
Abstract
Enhanced recovery program (ERP) was introduced in patients scheduled for colorectal surgical procedures to enhance gastrointestinal recovery and shorten their hospital stay. This study aims to evaluate the role of ERP in colorectal cancer patients. A prospective cohort study performed at National Cancer Institute-Cairo University including 50 patients with colorectal cancer treated between October 2016 and May 2017. They were divided in 2 equal groups: study group (ERP group) and control group (conventional protocol group). Incidence of postoperative morbidity was greater in the control group compared to the study group. Only the incidence of paralytic ileus was greater in the study group. The study group had a statistically significant hospital stay length compared to the control group. ERP was associated with lower incidence of postoperative morbidity excluding incidence of paralytic ileus; also, it was associated with a shorter hospital stay.
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Affiliation(s)
- Mamdouh Mohamed Mounir
- Surgical Oncology Department, National Cancer Institute-Cairo University, 1 Kasr El Aini Street, Fom El Khalig, Cairo, 11796 Egypt
| | - Mohamed Ibrahim Fahim
- Surgical Oncology Department, National Cancer Institute-Cairo University, 1 Kasr El Aini Street, Fom El Khalig, Cairo, 11796 Egypt
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2
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Rona K, Choi J, Sigle G, Kidd S, Ault G, Senagore AJ. Enhanced Recovery Protocol: Implementation at a County Institution with Limited Resources. Am Surg 2020. [DOI: 10.1177/000313481207801006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). Data regarding use of care plan, length of stay (LOS), and rates of postoperative complications and readmission were recorded. One hundred eleven patients were included in the study; however, complete use of the ERP after its introduction occurred in a total of 50 patients for a compliance rate of 60 per cent (95% confidence interval [CI], 49 to 70). Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days ( P = 0.002), and there was a trend toward decreased postoperative morbidity without an increase in readmission rate ( P = 0.61). Full implementation of an ERP for colorectal surgery faces many challenges in a resource-limited county institution; however, when fully applied, the ERP safely reduced overall LOS, which is important in cost containment.
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Affiliation(s)
- Kais Rona
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - J. Choi
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - G. Sigle
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - S. Kidd
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - G. Ault
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - A. J. Senagore
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
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3
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Pal AR, Mitra S, Aich S, Goswami J. Existing practice of perioperative management of colorectal surgeries in a regional cancer institute and compliance with ERAS guidelines. Indian J Anaesth 2019; 63:26-30. [PMID: 30745609 PMCID: PMC6341895 DOI: 10.4103/ija.ija_382_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background and Aims: Enhanced recovery after surgery (ERAS) protocol in colorectal surgery has been shown to result in reduced rates of postoperative complications and length of stay (LOS) in the hospital. Although there is clear guideline and evidences available, their implementation into daily clinical practice faces some difficulties. We aimed to audit the existing practice of perioperative care in colorectal surgeries and find out the adherence to ERAS protocol. Methods: We collected data from medical record of 215 patients undergoing colorectal surgery in a regional cancer institute of eastern India. The patient data were retrospectively collected, which included, demographic data, adherence to major components of ERAS pathway, postoperative complications, and length of hospital stay. Results: The median LOS after surgery was 9 days (interquartile range [IQR] 6-12.75). Approximately, 15% patients had postoperative complications. We found good adherence (more than 80%) to certain elements of ERAS such as preoperative counseling and nutritional assessments, selective bowel preparation, antibiotic and antithrombotic prophylaxis, etc. Conclusion: The audit revealed that compliance to individual ERAS elements were variable, which needed urgent modification for better adherence to ERAS guidelines.
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Affiliation(s)
- Angshuman Rudra Pal
- Department of Anaesthesiology, Critical Care and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Suparna Mitra
- Department of Anaesthesiology, Critical Care and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Sobhan Aich
- Department of Anaesthesiology, Critical Care and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Jyotsna Goswami
- Department of Anaesthesiology, Critical Care and Pain, Tata Medical Center, Kolkata, West Bengal, India
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4
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Bashankaev BN, Loriya IZ, Aliev VA, Glabay VP, Podzolkov VI, Shavgulidze KB, Yunusov BT. [Fast-tract: Therapist's role]. Khirurgiia (Mosk) 2018:59-64. [PMID: 30199053 DOI: 10.17116/hirurgia201808259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The modern model of inpatient surgical care of private and optimized state/govermental medical institutions allows us to change the paradigm of nosological attachment of the hospital bed to one profile of specialists for an adaptive model, when the wards can be reassigned depending on the needs of the hospital. In such multidisciplinary medical centers with mixed hospital beds without a nominal distinction in the nosological departments, a new therapeutic service is being developed - hospitalists, which provide a consistent curation of hospitalized patients, compensation of chronic therapeutic illnesses with patient's preparation for surgical interventions. Our work describes the experience of Fast Track recovery program with the active participation of a hospitalist in a surgical team, which is a new experience in the practice of Russian colorectal surgery.
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Affiliation(s)
- B N Bashankaev
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow? Russia; GMS clinicand hospitals, Moscow, Russia
| | - I Zh Loriya
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow? Russia; GMS clinicand hospitals, Moscow, Russia
| | - V A Aliev
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow? Russia; GMS clinicand hospitals, Moscow, Russia
| | - V P Glabay
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow? Russia
| | - V I Podzolkov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow? Russia
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Impact of Intravenous Acetaminophen on Perioperative Opioid Utilization and Outcomes in Open Colectomies. Anesthesiology 2018; 129:77-88. [DOI: 10.1097/aln.0000000000002227] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abstract
Background
The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients.
Methods
Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported.
Results
Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a −12.4% (99.5% CI, −15.2 to −9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: −22.6% (99.5% CI, −26.2 to −18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: −8.0% (99.5% CI, −11.0 to −4.9%) median 499 oral morphine equivalents versus −8.7% (99.5% CI, −14.4 to −2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects.
Conclusions
The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options.
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Abstract
The purpose of surgical treatment is to remove the lesions, repair tissue, and reconstruct organ function, but the process will inevitably cause certain degrees of trauma and stress. As a traumatic treatment, surgical treatment can produce a series of pathophysiological changes while achieving the therapeutic effect. Surgical complications are significantly associated with perioperative stress. Therefore, controlling operation-related stress can effectively improve prognosis. In order to reduce the incidence of surgical stress and postoperative complications and promote the rehabilitation of patients as soon as possible, the concept of fast track surgery has been put forward in recent years. It is supported by evidence-based medicine and subverts the traditional concept of surgery, optimizing the multidisciplinary cooperation in the perioperative treatment and rehabilitation process. Moreover, it accelerates the recovery of postoperative patients. Since the concept was put forward, it has been widely applied in European and American countries in the fields of gastroenterology, cardiothoracic surgery, orthopedics, urology, and gynecology. This paper briefly reviews the advances of fast track surgery in recent years.
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Affiliation(s)
- Ying Zhu
- Kailuan General Hospital, Tangshan 063000, Hebei Province, China
| | - Li-Jie An
- Kailuan General Hospital, Tangshan 063000, Hebei Province, China
| | - Jing-Yue Hou
- Kailuan General Hospital, Tangshan 063000, Hebei Province, China
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Liu XX, Pan HF, Jiang ZW, Zhang S, Wang ZM, Chen P, Zhao Y, Wang G, Zhao K, Li JS. "Fast-track" and "Minimally Invasive" Surgery for Gastric Cancer. Chin Med J (Engl) 2017; 129:2294-300. [PMID: 27647187 PMCID: PMC5040014 DOI: 10.4103/0366-6999.190659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols or fast-track (FT) programs enable a shorter hospital stay and lower complication rate. Minimally invasive surgery (MIS) is associated with a lesser trauma and a quicker recovery in many elective abdominal surgeries. However, little is known of the safety and effectiveness made by ERAS protocols combined with MIS for gastric cancer. The purpose of this study was to evaluate the safety and effectiveness made by FT programs and MIS in combination or alone. Methods: We summarized an 11-year experience on gastric cancer patients undergoing elective laparotomy or minimally invasive gastric resection in standard cares (SC) or FT programs during January 2004 to December 2014. A total of 984 patients were enrolled and assigned into four groups: open gastrectomies (OG) with SC (OG + SC group, n = 167); OG with FT programs (OG + FT group, n = 277); laparoscopic gastrectomies (LG) with FT programs (LG + FT group, n = 248); and robot-assisted gastrectomies (RG) with FT programs (RG + FT group, n = 292). Patients’ data were collected to evaluate the clinical outcome. The primary end point was the length of postoperative hospital stay. Results: The OG + SC group showed the longest postoperative hospital stay (mean: 12.3 days, median: 11 days, interquartile range [IQR]: 6–16 days), while OG + FT, LG + FT, and RG + FT groups recovered faster (mean: 7.4, 6.4, and 6.6 days, median: 6, 6, and 6 days, IQR: 3–9, 4–8, and 3–9 days, respectively, all P < 0.001). The postoperative rehabilitation parameters such as flatus time after surgery (4.7 ± 0.9, 3.1 ± 0.8, 3.0 ± 0.9, and 3.1 ± 0.9 days) followed the same manner. After 30 postoperative days’ follow-up, the total incidence of complications was 9.6% in OG + SC group, 10.1% in OG + FT group, 8.1% in LG + FT group, and 10.3% in RG + FT group. The complications showed no significant differences between the four groups (all P > 0.05). Conclusions: ERAS protocols alone could significantly bring fast recovery after surgery regardless of the surgical technique. MIS further reduces postoperative hospital stay. It is safe and effective to apply ERAS protocols combined with MIS for gastric cancer.
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Affiliation(s)
- Xin-Xin Liu
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002; Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Hua-Feng Pan
- Department of General Surgery, The First People's Hospital of Yangzhou, Clinical Medical School, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Zhi-Wei Jiang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Shu Zhang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Zhi-Ming Wang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Ping Chen
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Yan Zhao
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, Yangzhou, Jiangsu 225001, China
| | - Gang Wang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Kun Zhao
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Jie-Shou Li
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China
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Peng F, Liu S, Hu Y, Yu M, Chen J, Liu C. Influence of perioperative nonsteroidal anti-inflammatory drugs on complications after gastrointestinal surgery: A meta-analysis. ACTA ACUST UNITED AC 2017; 54:121-128. [PMID: 28089636 DOI: 10.1016/j.aat.2016.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/18/2016] [Accepted: 11/21/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are a key part of multimodal perioperative analgesia. This study aimed to evaluate the influence of perioperative NSAIDs application on complications after gastrointestinal surgery by using meta-analysis. METHODS A systematic review of published literature was conducted by searching computerized databases including PubMed, CBM, Springer, Chinese Academic Journals, and China Info since the databases were published until June 2015. The articles and retrospective references regarding complications after gastrointestinal surgery were collected to compare postoperative complications associated with NSAIDs or other analgesics. After they were assessed by randomized controlled trials and extracted by the standard of the Jadad systematic review, the homogeneous studies were pooled using RevMan 5.3 software. The meta-analysis was performed on five postoperative complications: postoperative anastomotic leak, cardiovascular events, surgical site infection, nausea and vomiting, and intestinal obstruction. RESULTS Twelve randomized controlled trials involving 3829 patients met the inclusion criteria. The results of meta-analyses showed the following: (1) postoperative anastomotic leak: NSAIDs (including selective and nonselective NSAIDs) increased the incidence of anastomotic leak [odds ratio (OR)=3.02, 95% confidence interval (CI): 2.16-4.23, p=0.00001]. Further results showed that nonselective NSAIDs significantly increased the incidence of anastomotic leak (OR=2.96, 95% CI: 1.99-4.42, p<0.00001), and selective NSAIDs had no significant difference as compared with the control group using other analgesics (OR=2.27, 95% CI: 0.68-7.56, p=0.18); (2) postoperative cardiovascular events: NSAIDs (selective and nonselective NSAIDs) had no difference when compared with other analgesics (OR=0.50, 95% CI: 0.23-1.12, p=0.09); (3) postoperative surgical site infection: NSAIDs (selective and nonselective NSAIDs) and other analgesics had no difference in surgical site infection (OR=0.77, 95% CI: 0.52-1.15, p=0.20); (4) postoperative nausea and vomiting: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of nausea and vomiting (OR=0.53, 95% CI: 0.34-0.81, p=0.003); (5) postoperative intestinal obstruction: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of intestinal obstruction (OR=0.35, 95% CI: 0.13-0.89, p=0.03). CONCLUSIONS The meta-analysis suggests that postoperative NSAIDs, especially nonselective NSAIDs, could increase the incidence of anastomotic leak. NSAIDs could decrease postoperative nausea and vomiting and intestinal obstruction, but showed no difference in cardiovascular events and surgical site infection as compared with other analgesics.
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Affiliation(s)
- Fang Peng
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China; Department of Anesthesiology, Northern Jiangsu People's Hospital, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu, China
| | - Shijiang Liu
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Youli Hu
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Min Yu
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Cunming Liu
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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Otero JJ, Detriche O, Mommaerts MY. Fast-track Orthognathic Surgery: An Evidence-based Review. Ann Maxillofac Surg 2017; 7:166-175. [PMID: 29264281 PMCID: PMC5717890 DOI: 10.4103/ams.ams_106_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The aim of this study was to establish a fast-track protocol for bimaxillary orthognathic surgery (OGS). Fast-track surgery (FTS) is a multidisciplinary approach where the pre-, intra-, and postoperative management is focusing maximally on a quick patient recovery and early discharge. To enable this, the patients' presurgical stress and postsurgical discomfort should be maximally reduced. Both referral patterns and expenses within the health-care system are positively influenced by FTS. University hospital-literature review through Medline, Embase, and the Cochrane Library (January 2000-July 2016) using the following words - "fast track, enhanced recovery, multimodal, and perioperative care" - to define a protocol evidence based for OGS, as well as evidenced-based medicine search of every term added to the protocol during the same period. The process has resulted in an OGS protocol that may improve the outcome of the patient through several nonoperative and operative measures such as preoperative patient education and intra/postoperative measures that should improve overall patient satisfaction, decrease morbidity such as postoperative nausea, headache, dizziness, pain, and intubation discomfort, and shorten hospital stay. A literature review allowed us to fine-tune a fast-track protocol for uncomplicated OGS that can be prospectively studied against currently applied ones.
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Affiliation(s)
- Joel Joshi Otero
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Olivier Detriche
- Department of Anesthesiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Maurice Yves Mommaerts
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
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10
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El Chaar M, Stoltzfus J, Claros L, Wasylik T. IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center. J Gastrointest Surg 2016; 20:715-24. [PMID: 26842692 DOI: 10.1007/s11605-016-3088-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/19/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative. OBJECTIVE The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients' pain, satisfaction, and hospital length of stay. METHODS In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes. RESULTS Mean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2%, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185). CONCLUSIONS Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.
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Affiliation(s)
- Maher El Chaar
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA.
| | - Jill Stoltzfus
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
| | - Leonardo Claros
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
| | - Tara Wasylik
- Medical School of Temple University/St. Luke's University Health Network, 240 Cetronia Road, Suite 205, North Allentown, PA, 18104, USA
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Abstract
Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.
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Affiliation(s)
- Aditya J Nanavati
- Department of General Surgery, K.B. Bhabha Hospital, Bandra, Mumbai, Maharashtra, India
| | - S Prabhakar
- Department of General Surgery, L.T.M.G.H., Sion, Mumbai, Maharashtra, India
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12
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El Chaar M, Claros L, Ezeji GC, Miletics M, Stoltzfus J. Improving outcome of bariatric surgery: best practices in an accredited surgical center. Obes Surg 2015; 24:1057-63. [PMID: 24563069 DOI: 10.1007/s11695-014-1209-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The number of laparoscopic bariatric procedures being performed in the USA has increased dramatically in the past decade. Because of limited health-care resources, hospital administrators and insurance carriers are placing emphasis on length of stay and patient outcomes. The goal of this study was to evaluate the feasibility and safety of a clinical pathway in managing patients undergoing bariatric surgery in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center. The setting was a university hospital in USA. A retrospective analysis of data collected prospectively on patients undergoing bariatric surgery at St Luke's University was performed. Patients included underwent either a laparoscopic Roux-en-Y gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). Patients were subjected to a clinical protocol and discharged when discharge criteria were met. The primary outcomes were length of stay, 30 day readmission, complication, and reoperation rates. A cost analysis of the savings accrued was also performed. Two hundred twenty-nine patients were included in our analysis (80.4% females and 19.6% males). Seventy-one patients (31%) underwent LSG, and 158 patients (69%) underwent LRYGB. The average length of stay was 32.45 h (range 24-72 h). The 30-day readmission rate was 3.0% (7/229 patients). The 30 day complication rate (including intervention, reintubation, and reoperation) was 2.6% (6/229). The 30 day mortality rate was 0. The average prospective cost savings were $2,016 and $1,209 per LRYGB and LSG patient, respectively. Our bariatric surgery clinical protocol is feasible and safe with substantial prospective cost savings at St Luke's University and Health Network. Patients subjected to our protocol have low readmission and complication rates. Further studies are needed to fully elucidate the benefit of this innovative new protocol in bariatric surgery.
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Affiliation(s)
- Maher El Chaar
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, The Medical School of Temple University/St Luke's University Hospital and Health Network, 1736 Hamilton Boulevard, Allentown, PA, 18104, USA,
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Yin X, Zhao Y, Zhu X. Comparison of fast track protocol and standard care in patients undergoing elective open colorectal resection: a meta-analysis update. Appl Nurs Res 2014; 27:e20-6. [DOI: 10.1016/j.apnr.2014.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/17/2014] [Accepted: 07/22/2014] [Indexed: 12/15/2022]
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14
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Carter J, Elliott S, Kaplan J, Lin M, Posselt A, Rogers S. Predictors of hospital stay following laparoscopic gastric bypass: analysis of 9,593 patients from the National Surgical Quality Improvement Program. Surg Obes Relat Dis 2014; 11:288-94. [PMID: 25443054 DOI: 10.1016/j.soard.2014.05.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/29/2014] [Accepted: 05/08/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bariatric centers face pressure to reduce hospitalization to contain costs, and some centers have sought to develop "fast-track" protocols. There is limited data to identify which patients require a longer hospital stay after gastric bypass, and therefore would be inappropriate for fast tracking. The objectives of this study were to determine (1) whether most patients in the United States who underwent laparoscopic gastric bypass required>1 day of hospitalization to recover; (2) whether hospital length of stay can be predicted by factors known before or after the operation. METHODS We reviewed all laparoscopic gastric bypass operations reported to the American College of Surgeons National Surgical Quality Improvement Program in 2011. Revision and open procedures were excluded. Patient and procedural characteristics, length of stay, readmissions, and 30-day morbidity and mortality were reviewed. Predictors of longer hospitalization (defined as≥3 days) were identified by multivariate analysis. RESULTS Of 9,593 laparoscopic gastric bypass operations, median length of stay was 2 days (range 0-544) and 26% of patients required≥3 days of hospitalization. In multivariate analysis, longer hospitalization was predicted by diabetes, chronic obstructive pulmonary disease, bleeding diathesis, renal insufficiency, hypoalbuminemia, prolonged operating time, and resident involvement with the procedure, but not by patient age, sex, body mass index, and other co-morbidities. CONCLUSION Patient characteristics and operative details predict length of hospitalization after laparoscopic gastric bypass. Such data can be used to identify patients inappropriate for fast-track protocols.
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Affiliation(s)
- Jonathan Carter
- Department of Surgery, University of California-San Francisco, San Francisco, California.
| | - Steven Elliott
- Department of Surgery, University of California-San Francisco, San Francisco, California
| | - Jennifer Kaplan
- Department of Surgery, University of California-San Francisco, San Francisco, California
| | - Matthew Lin
- Department of Surgery, University of California-San Francisco, San Francisco, California
| | - Andrew Posselt
- Department of Surgery, University of California-San Francisco, San Francisco, California
| | - Stanley Rogers
- Department of Surgery, University of California-San Francisco, San Francisco, California
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Higgs S, Henry R, Glackin M. Acute pain services following surgery for colorectal cancer. ACTA ACUST UNITED AC 2014; 23:S4, S6, S8-11. [DOI: 10.12968/bjon.2014.23.sup2.s4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Simon Higgs
- for Inpatient Pain, South Eastern Health and Social Care Trust
- Oncology and Palliative Care; at the School of Nursing and Midwifery, Queen's University Belfast
| | - Richard Henry
- Oncology and Palliative Care; at the School of Nursing and Midwifery, Queen's University Belfast
| | - Marie Glackin
- Oncology and Palliative Care; at the School of Nursing and Midwifery, Queen's University Belfast
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Agrafiotis AC, Corbeau M, Buggenhout A, Katsanos G, Ickx B, Van de Stadt J. Enhanced recovery after elective colorectal resection outside a strict fast-track protocol. A single centre experience. Int J Colorectal Dis 2014; 29:99-104. [PMID: 23982426 DOI: 10.1007/s00384-013-1767-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of "fast-track" protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patient and therefore applicable only to a limited number of patients. AIM In order to optimise, in every aspect, the postoperative recovery of each patient undergoing an elective colorectal resection inside our institution, we set up a "soft" enhanced recovery programme. MATERIAL-METHODS A retrospective analysis was conducted in 92 patients evaluating the respective impact of protocol application throughout the duration of the hospital stay. RESULTS When all the required measures of our protocol were correctly implemented, the median discharge day was postoperative day 3 (range 3-5 days). On the contrary, when deviations occurred, they resulted in longer hospital stay (p < 0.001). Patients operated by laparoscopy were discharged earlier than patients operated by laparotomy (p < 0.001). The use of nasogastric tube and postoperative drainage prolonged significantly the length of stay (p = 0.001 and p < 0.001 respectively). When the urinary catheter was not removed or oral feeding not resumed on postoperative day 1, the patients were discharged later (p < 0.001). CONCLUSIONS There are substantial possibilities of optimising the recovery process after an elective colorectal resection, outside a strict fast-track protocol.
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Affiliation(s)
- A C Agrafiotis
- Clinic of Colorectal Surgery, Department of Digestive Surgery, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium,
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Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios. Cir Esp 2013; 91:638-44. [DOI: 10.1016/j.ciresp.2013.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 11/20/2012] [Accepted: 01/05/2013] [Indexed: 12/15/2022]
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Keller DS, Delaney CP. The Role of Enhanced Recovery Pathways in the Setting of Minimally Invasive Colorectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Meyer-Bender A, Kern A, Pollwein B, Crispin A, Lang PM. Incidence and predictors of immediate complications following perioperative non-obstetric epidural punctures. BMC Anesthesiol 2012; 12:31. [PMID: 23227938 PMCID: PMC3566923 DOI: 10.1186/1471-2253-12-31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 11/29/2012] [Indexed: 12/04/2022] Open
Abstract
Background Epidural Anesthesia (EA) is a well-established procedure. The aim of the present study was to evaluate the incidence of immediate complications following epidural puncture, such as sanguineous puncture, accidental dural perforation, unsuccessful catheter placement or insufficient analgesia and to identify patient and maneuver related risk factors. Methods A total of 7958 non-obstetrical EA were analyzed. The risk of each complication was calculated according to the preconditions and the level of puncture. For probabilistic evaluation we used a logistic regression model with forward selection. Results The risk of sanguineous puncture (n = 247, 3.1%) increases with both the patient’s age (P = 0.013) and the more caudal the approach (P < 0.01). Dural perforation (n = 123, 1.6%) was found to be influenced only by advanced age (P = 0.019). Unsuccessful catheter placement (n = 68, 0.94%) occurred more often in smaller individuals (P < 0.001) and at lower lumbar sites (P < 0.01). Amongst all cases with successful catheter placement a (partial) insufficient analgesia was found in 692 cases (8.8%). This risk of insufficient analgesia decreased with patient’s age (P <0 .01), being least likely for punctures of the lower thoracic spine (P < 0.001). Conclusions Compared to more cranial levels, EA of the lower spine is associated with an increased risk of sanguineous and unsuccessful puncture. Insufficient analgesia more often accompanies high thoracic and low lumbar approaches. The risk of a sanguineous puncture increases in elderly patients. Gender, weight and body mass index seem to have no influence on the investigated complications.
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Affiliation(s)
- Andreas Meyer-Bender
- Department of Anaesthesiology, University Hospital of Munich, Marchioninistr, 15, 81377, Munich, Germany.
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Chen Hu J, Xin Jiang L, Cai L, Tao Zheng H, Yuan Hu S, Bing Chen H, Chang Wu G, Fei Zhang Y, Chuan Lv Z. Preliminary experience of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer. J Gastrointest Surg 2012; 16:1830-9. [PMID: 22854954 DOI: 10.1007/s11605-012-1969-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 07/15/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and effectiveness of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer. METHODS Eighty-eight eligible patients were randomly assigned into four groups: (1) fast-track surgery (FTS) + laparoscopy-assisted radical distal gastrectomy (LADG), treated with LADG and FTS treatment; (2) LADG, treated with LADG and traditional treatment; (3) FTS + open distal grastectomy (ODG), treated with ODG and FTS treatment; and (4) ODG, treated with ODG and traditional treatment. The clinical parameters and serum indicators were compared. RESULTS Compared with the ODG group, the other three groups had earlier first flatus and shorter postoperative hospital stay (all P <0.01; all P <0.05), especially in the FTS + LADG group. The level of ALB was higher in the FTS + LADG group than in the LADG group at 4 and 7 days after surgery (P <0.05, P <0.01). The level of CRP in the FTS + LADG group was lower than in the FTS+ODG group at 4 and 7 days after surgery (P <0.05, P <0.05). The FTS + ODG group had lowest medical costs. CONCLUSION Combination of FTS and LADG in gastric cancer is safe, feasible, and efficient and can improve nutritional status, lessen postoperative stress, and accelerate postoperative rehabilitation. Compared with FTS + ODG and LADG, its advantages were limited in short-term follow-up.
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Affiliation(s)
- Jin Chen Hu
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, No. 20 Yuhuangding East Road, Yantai, Shandong, 264000, China
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Varela J. Ahorrar con criterio clínico desde la perspectiva del ámbito hospitalario. Med Clin (Barc) 2012; 139:165-70. [DOI: 10.1016/j.medcli.2012.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/10/2012] [Accepted: 01/17/2012] [Indexed: 12/26/2022]
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Fast track surgery particularly in case of patients undergoing colonic resection. POLISH JOURNAL OF SURGERY 2012; 83:55-61. [PMID: 22166244 DOI: 10.2478/v10035-011-0009-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zhou JJ, Li J, Ying XJ, Song YM, Chen R, Chen G, Yan M, Ding KF. Fast track multi-discipline treatment (FTMDT trial) versus conventional treatment in colorectal cancer--the design of a prospective randomized controlled study. BMC Cancer 2011; 11:494. [PMID: 22111914 PMCID: PMC3254142 DOI: 10.1186/1471-2407-11-494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 11/24/2011] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopy-assisted surgery, fast-track perioperative treatment are both increasingly used in colorectal cancer treatment, for their short-time benefits of enhanced recovery and short hospital stays. However, the benefits of the integration of the Laparoscopy-assisted surgery, fast-track perioperative treatment, and even with the Xelox chemotherapy, are still unknown. In this study, the three treatments integration is defined as "Fast Track Multi-Discipline Treatment Model" for colorectal cancer and this model extends the benefits to the whole treatment process of colorectal cancer. The main purpose of the study is to explore the feasibility of "Fast Track Multi-Discipline Treatment" model in treatment of colorectal cancer. METHODS The trial is a prospective randomized controlled study with 2 × 2 balanced factorial design. Patients eligible for the study will be randomized to 4 groups: (I) Laparoscopic surgery with fast track perioperative treatment and Xelox chemotherapy; (II) Open surgery with fast track perioperative treatment and Xelox chemotherapy; (III) Laparoscopic surgery with conventional perioperative treatment and mFolfox6 chemotherapy; (IV) Open surgery with conventional perioperative treatment and mFolfox6 chemotherapy. The primary endpoint of this study is the hospital stays. The secondary endpoints are the quality of life, chemotherapy related adverse events, surgical complications and hospitalization costs. Totally, 340 patients will be enrolled with 85 patients in each group. CONCLUSIONS The study initiates a new treatment model "Fast Track Multi-Discipline Treatment" for colorectal cancer, and will provide feasibility evidence on the new model "Fast Track Multi-Discipline Treatment" for patients with colorectal cancer. TRIAL REGISTRATION ClinicalTrials.gov: NCT01080547.
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Affiliation(s)
- Jiao-Jiao Zhou
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Jun Li
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Xiao-Jiang Ying
- Department of Anorectum, People's Hospital of Shaoxing, 568 Zhong-Xing North Rd, Shaoxing, Zhejiang 312000, China
| | - Yong-Mao Song
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Rong Chen
- Department of Anus and Large Intestine, Second Affiliated Hospital, Wenzhou Medicine College, 109 Xue-Yuan West Rd, Wenzhou, Zhejiang 325027, China
| | - Gang Chen
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Min Yan
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
| | - Ke-Feng Ding
- Department of Surgical Oncology, Second Affiliated Hospital, and The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University College of Medicine, 88 Jie-Fang Rd, Hangzhou, Zhejiang 310009, China
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Stein SL. Incorporating Enhanced Care Pathways into Colorectal Practice. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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