Impact of Fast-Track Postoperative Care on Intestinal Function, Pain, and Length of Hospital Stay After Laparoscopic Radical Prostatectomy

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of fast-track surgery on postoperative wound pain in patients with prostate cancer: A meta-analysis

Fast track surgery (FTS) is widely used in many procedures and has been shown to reduce complications and accelerate recovery. However, no studies have been conducted to assess their effectiveness in treating wounds after radical prostatectomy (RP). The objective of this study was to evaluate the impact of FTS on RP. We went through 4 major databases. A study was conducted by PubMed, the Cochrane Library, Embase, and the Web of Science to determine the effect of comparison of FTS versus conventional surgery in RP on postoperative wound complications as of 1 July 2023. Based on the review of literature, data extraction and literature quality assessment, we conducted meta-analyses with RevMan 5.3. In the course of the study, the researchers selected 6 of the 404 studies to be analysed according to exclusion criteria. Data analysis showed that the FTS method reduced the postoperative pain associated with VAS and also decreased the rate of postoperative complications in post-surgical patients. However, there was no significant difference between FTS and conventional surgery in terms of blood loss, operation time, and postoperative infection rate. Therefore, generally speaking, FTS has less impact on postoperative complications in patients with minimal invasive prostatic cancer, but it does reduce postoperative pain and total postoperative complications.

A Scientometric Analysis and Visualization Discovery of Enhanced Recovery After Surgery

Background

Enhanced recovery after surgery (ERAS), a new clinical surgical concept, has been applied in many surgical disciplines with good clinical results for the past 20 years. Bibliometric analysis is an effective method to quantitatively evaluate the academic productivity. This report aimed to perform a scientometric analysis of the ERAS research status and research hotspots.

Methods

Comprehensive scientific mapping analysis of a wide range of literature metadata using the scientometric tools, including the Bibliometrix R Package, Biblioshiny, and CiteSpace. Data were retrieved from the Web of Science Core Collection database of original articles from 2001 to 2020. Specific indicators and maps were analyzed to show the co-authorship, co-institute, co-country, co-citation, and international cooperation. Automatic literature screening, unsupervised cluster filtering, and topic cluster identification methods were used to display the conceptual framework and thematic evolution.

Results

A total of 1,403 research projects drafted by 6,966 authors and published in 413 sources were found. There was an exponential growth in the number of publications on ERAS. There were 709 collaborations between authors from different countries, and the US, China, and the UK had the greatest number of publications. The WORLD JOURNAL OF SURGERY, located in Bradford’s Law 1, had the highest number of published articles (n = 1,276; total citations = 3,193). CiteSpace network analysis revealed 15 highly correlated cluster ERAS studies, and the earliest study was on colonic surgery, and ERAS was recently applied in cardiac surgery. The etiology of ERAS is constantly evolving, with surgery and length of hospital as the main topics. Meta-analyses and perioperative care have tended to decline.

Conclusion

This is the first scientometric analysis of ERAS to provide descriptive quantitative indicators. This can provide a better understanding of how the field has evolved over the past 20 years, help identify research trends, and provide insights and research directions for academic researchers, policymakers, and medical practitioners who want to collaborate in these areas in the future.

Clinical efficacy of an enhanced recovery after surgery protocol in patients undergoing robotic-assisted laparoscopic prostatectomy

Objective

To evaluate the application of an enhanced recovery after surgery (ERAS) protocol in patients undergoing robot-assisted laparoscopic prostatectomy (RALP).

Methods

We conducted a retrospective cohort study of 136 patients who underwent RALP between August 2017 and June 2018 as the control group and a prospective analysis of 106 patients who underwent RALP between January 2019 and January 2020 as the ERAS group. ERAS focused on preoperative education, nutritional intervention, electrolyte solution intake, restrictive fluid infusion, body warming, no indwelling central venous catheter, use of nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and eating recovery.

Results

The times from RALP to the first intake of clear liquid; first ambulation; first defecation; first fluid, semi-liquid, and general diet; drain removal; and length of hospital stay (LOS) were significantly shorter, and operative time, fluid infusion within 24 hours, postoperative day (POD) 1 albumin, POD 1 hemoglobin, and POD 2 drainage were significantly higher in the ERAS group. Five patients (3.8%) in the ERAS group developed postoperative complications (urine leakage, n = 4; intestinal obstruction, n = 1), while 1 patient (0.7%) in the control group developed intestinal obstruction.

Conclusions

ERAS effectively accelerated patient rehabilitation and reduced the LOS for patients undergoing RALP.

Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial

OBJECTIVES

Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy.

MATERIALS AND METHODS

We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively.

RESULTS

Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support.

CONCLUSIONS

While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.

PROSPECT guidelines update for evidence-based pain management after prostatectomy for cancer

The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.

Effect of Robot-assisted Surgery on Anesthetic and Perioperative Management for Minimally Invasive Radical Prostatectomy under Combined General and Epidural Anesthesia

BACKGROUND

Robot-assisted surgery and pure laparoscopic surgery are available for minimally invasive radical prostatectomy (MIRP). The differences in anesthetic management between these two MIRPs under combined general and epidural anesthesia (CGEA) remain unknown. This study therefore aimed to determine the effects of robot-assisted surgery on anesthetic and perioperative management for MIRP under CGEA.

METHODS

This retrospective observational study analyzed data from patients' electronic medical records. Data on demographics, intraoperative variables, postoperative complications, and hospital stays after MIRPs were compared between patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) and those treated by pure laparoscopic radical prostatectomy (LRP).

RESULTS

There were no differences in background data between the 102 who underwent RALP and 112 who underwent LRP. Anesthesia and surgical times were shorter in the RALP group than in the LRP group. Doses of anesthetics, including intravenous opioids, and epidural ropivacaine, were lower in the RALP group. Although estimated blood loss and volume of colloid infusion were lower in the RALP group, the volume of crystalloid infusion was larger. Intraoperative allogeneic transfusion was not required in either group. There was no difference between groups in the incidences of postoperative cardiopulmonary complications or postoperative nausea and vomiting. Hospital stays after the procedure were shorter in the RALP group.

CONCLUSIONS

Robot-assisted surgery required varied consumption of anesthetics and infusion management during MIRP under GCEA. It also shortened postoperative hospital stays, without increasing rates of postoperative complications.

Comparison between epidural technique and mid-axillary ultrasound-guided TAP block for postoperative analgesia of laparoscopic radical prostatectomy: a quasi-randomized clinical trial

BACKGROUND

Our goal was to evaluate whether TAP block offers the same analgesic pain control compared to epidural technique in laparoscopic radical prostatectomy surgery through the morphine consumption in the first 48 hours.

METHODS

In this study, 45 patients were recruited and assigned to either TAP or epidural. The main study outcome was morphine consumption during the first 48 hours after surgery. Other data recorded were pain at rest and upon movement, technique-related complications and adverse effects, surgical and postoperative complications, length of surgery, need for rescue analgesia, postoperative nausea and vomiting, start of intake, sitting and perambulation, first flatus, and length of in-hospital stay.

RESULTS

From a total of 45 patients, two were excluded due to reconversion to open surgery (TAP group = 20; epidural group = 23). There were no differences in morphine consumption (0.96 vs. 0.8 mg; p = 0.78); mean postoperative VAS pain scores at rest (0.7 vs. 0.5; p = 0.72); or upon movement (1.6 vs. 1.6; p = 0.32); in the TAP vs. epidural group, respectively. Sitting and perambulation began sooner in TAP group (19 vs. 22 hours, p = 0.03; 23 vs. 32 hours, p = 0.01; respectively). The epidural group had more technique-related adverse effects.

CONCLUSION

TAP blocks provide the same analgesic quality with optimal pain control than epidural technique, with less adverse effects.

Clinical efficacy of enhanced recovery after surgery (ERAS) program in patients undergoing radical prostatectomy: a systematic review and meta-analysis

Background

Enhanced recovery after surgery (ERAS) protocol has been identified to be beneficial in the amount of operations such as gastrointestinal surgery. However, the efficacy and safety in robot-assisted laparoscopic prostatectomy/laparoscopic radical prostatectomy (RALP/LRP) still remain controversial.

Method

We searched randomized controlled trials and retrospective cohort studies comparing ERAS versus conventional care for prostate cancer patients who have undergone RALP/LRP. ERAS-related data were extracted, and quality of included studies was assessed using the Newcastle-Ottawa quality assessment scale and the Jadad scale.

Result

As a result, seven trials containing 784 prostate cancer patients were included. ERAS was observed to be significantly associated with shorter length of hospital stay (SMD − 2.55, 95%CI − 3.32 to − 1.78, P < 0.05), shorter time to flatus (SMD − 1.55, 95%CI − 2.26 to − 0.84, P < 0.05), shorter time to ambulate (SMD − 6.50, 95%CI − 10.91 to − 2.09, P < 0.05), shorter time to defecate (SMD − 2.80, 95%CI − 4.56 to − 1.04, P < 0.05), and shorter time to remove drainage tube (SMD − 2.72, 95%CI − 5.31 to − 0.12, P < 0.05). Otherwise, no significant difference was reported in other measurements.

Conclusions

In conclusion, ERAS can reduce length of hospital stay, time to flatus, time to defecate, time to ambulate, and time to remove drainage tube in prostate cancer patients who have undergone RALP/LRP compared with conventional care.

The effect of intraoperative lidocaine infusion on opioid consumption and pain after totally extraperitoneal laparoscopic inguinal hernioplasty: a randomized controlled trial

BACKGROUND

As a component of multimodal analgesia, the administration of systemic lidocaine is a well-known technique. We aimed to evaluate the efficacy of lidocaine infusion on postoperative pain-related outcomes in patients undergoing totally extraperitoneal (TEP) laparoscopies inguinal hernioplasty.

METHODS

In this randomized controlled double-blind study, we recruited 64 patients to receive either lidocaine 2% (intravenous bolus 1.5 mg. kg ^- 1 followed by an infusion of 2 mg. kg^- 1. h^- 1), or an equal volume of normal saline. The infusion was initiated just before the induction of anesthesia and discontinued after tracheal extubation. The primary outcome of the study was postoperative morphine equivalent consumption up to 24 h after surgery. Secondary outcomes included postoperative pain scores, nausea/vomiting (PONV), sedation, quality of recovery (scores based on QoR-40 questionnaire), patient satisfaction, and the incidence of chronic pain.

RESULTS

The median (IQR) cumulative postoperative morphine equivalent consumption in the first 24 h was 0 (0-1) mg in the lidocaine group and 4 [1-8] mg in the saline group (p < 0.001). Postoperative pain intensity at rest and during movement at various time points in the first 24 h were significantly lower in the lidocaine group compared with the saline group (p < 0.05). Fewer patients reported PONV in the lidocaine group than in the saline group (p < 0.05). Median QoR scores at 24 h after surgery were significantly better in the lidocaine group (194 (194-196) than saline group 184 (183-186) (p < 0.001). Patients receiving lidocaine were more satisfied with postoperative analgesia than those receiving saline (p = 0.02). No difference was detected in terms of postoperative sedation and chronic pain after surgery.

CONCLUSIONS

Intraoperative lidocaine infusion for laparoscopic TEP inguinal hernioplasty reduces opioid consumption, pain intensity, PONV and improves the quality of recovery and patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov- NCT02601651. Date of registration: November 10, 2015.

Impact of enhanced recovery after surgery or fast track surgery pathways in minimally invasive radical prostatectomy: a systematic review and meta-analysis

Background

The enhanced recovery after surgery (ERAS) and fast track surgery (FTS) protocols have been applied to a variety of surgeries and have been proven to reduce complications, accelerate rehabilitation, and reduce medical costs. However, the effectiveness of these protocols in minimally invasive radical prostatectomy (miRP) is still unclear. Thus, this study aimed to evaluate the impact of ERAS and FTS protocols in miRP.

Methods

We searched PubMed, Cochrane Library, Embase, and Web of Science databases to collect randomized and observational studies comparing ERAS/FTS versus conventional care in miRP up to July 1, 2019. After screening for inclusion, data extraction, and quality assessment by two independent reviewers, the meta-analysis was performed with the RevMan 5.3 and STATA 15.1 software. Results were expressed as risk ratio (RR) and weighted mean difference (WMD) with 95% confidence intervals (CIs).

Results

In total, 11 studies involving 1,207 patients were included. Pooled data showed that ERAS/FTS was associated with a significant reduction in length of stay (LOS) (WMD: -2.41 days, 95% CI: -4.00 to -0.82 days, P=0.003), time to first anus exhaust (WMD: -0.74 days, 95% CI: -1.14 to -0.34 days, P=0.0003), and lower incidence of postoperative complications (RR: 0.70, 95% CI: 0.53 to 0.92, P=0.01). No significant differences were found between groups for operation time, estimated blood loss, postoperative pain, blood transfusion rate, and readmission rate (P>0.01).

Conclusions

Our meta-analysis suggests that the ERAS/FTS protocol is safe and effective in miRP. However, more extensive, long-term, prospective, multicenter follow-up studies, and randomized controlled trials (RCTs) are required to validate our findings.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

METHODS

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups.

CONCLUSIONS

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

Effects of preoperative intrathecal morphine on postoperative intravenous morphine dosage: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The purpose of this systematic review is to describe the effect of preoperative intrathecal morphine (ITM) on postoperative intravenous (IV) morphine dosage during the first postoperative day. This systematic review will compare the postoperative IV morphine dosage of patients receiving ITM plus morphine morphine-based patient-controlled analgesia (PCA), to patients receiving PCA morphine without ITM. This will establish the magnitude of the postoperative morphine sparing effect of ITM.This review aims to answer the following specific question: In adult abdominal and thoracic surgery patients undergoing general anesthesia (GA), what is the effect of ITM plus PCA morphine, compared to PCA morphine alone, on total IV morphine dosage (in milligrams) during the first 24 hours after surgery?

Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery

OBJECTIVE

To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures.

BACKGROUND

ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols.

METHODS

A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs.

RESULTS

A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis.

CONCLUSIONS

ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.

Research progress of fast track surgery

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.

[Half-day case robotic radical prostatectomy. Surgery of the future? A case report]

INTRODUCTION

Robotics and ambulatory are modern applications of surgery. This case study proves the feasibility of robot-assisted radical prostatectomy as an outpatient procedure.

METHOD

This report highlights the first, half-day, robotic prostatectomy performed on a 57-year-old man with localized prostate cancer. This operation was proposed to the subject because of his excellent physical condition and favorable environmental factors. He chose to undergo the surgery voluntarily. He underwent a nerve sparing radical prostatectomy. Target-controlled infusion propofol was used in perioperative sedation and analgesia. Postoperative evaluation criteria was made with the Visual Analog Scale of Pain Intensity (VASPI), Chung score and a patient satisfaction survey.

RESULTS

No perioperative or postoperative complications were reported. Blood loss was low (75 mL). The patient stayed less than 12 hours in the ambulatory unit thanks to a rapid recovery. The patient returned home after reporting a Chung score of 10. No hospital readmission was necessary. Functional results were: a bowel movement on day 1, back to work on day 2, normal urinary continence on day 8, a correct erectile function on day 9. Oncological results revealed negative surgical margins for cancer and PSA postoperative<0.03 ng/mL.

CONCLUSION

Ambulatory robotic radical prostatectomies can be performed on voluntarily-selected patients without affecting the high quality of urological surgery outcomes.

Optimal pain management for radical prostatectomy surgery: what is the evidence?

BACKGROUND

Increase in the diagnosis of prostate cancer has increased the incidence of radical prostatectomy. However, the literature assessing pain therapy for this procedure has not been systematically evaluated. Thus, optimal pain therapy for patients undergoing radical prostatectomy remains controversial.

METHODS

Medline, Embase, and Cochrane Central Register of Controlled Trials were searched for studies assessing the effects of analgesic and anesthetic interventions on pain after radical prostatectomy. All searches were conducted in October 2012 and updated in June 2015.

RESULTS

Most treatments studied improved pain relief and/or reduced opioid requirements. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis and consensus recommendations.

CONCLUSIONS

This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.

Enhancing surgical performance outcomes through process-driven care: a systematic review

BACKGROUND

Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care.

METHODS

A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded.

RESULTS

Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear.

CONCLUSION

Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.

Fast-track programs versus traditional care in hepatectomy: a meta-analysis of randomized controlled trials

BACKGROUND/AIMS

The role of fast-track programs in hepatectomy is unclear. This meta-analysis aimed to evaluate the efficacy and safety of fast-track programs versus traditional care.

METHODS

We searched Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar for relevant randomized controlled trials (RCTs) comparing fast-track with traditional care in hepatectomy. Length of hospital stay, time to first flatus, postoperative complications, operating time, and intraoperative blood loss were assessed. Meta-analyses were performed using RevMan 5.2 software.

RESULTS

Four original RCTs with 372 patients were included: 187 in the fast-track and 185 in the traditional care group. Fast-track patients had shorter hospital stay (WMD -2.32; 95% CI, -3.54 to -1.11; p < 0.001) and time to first flatus (WMD -0.99; 95% CI, -1.15 to -0.84; p < 0.001), and less postoperative complications (RR 0.66; 95% CI, 0.47 to 0.93; p < 0.05). However, there was significant heterogeneity between the studies regarding hospital stay (I(2) = 88%; p < 0.001). Operating time and intraoperative blood loss were not different.

CONCLUSIONS

Patients in fast-track programs had less time to first flatus and postoperative complications compared to traditional care. Fast-track programs may reduce the length of hospital stay. Larger, higher quality prospective RCTs are necessary to draw more robust conclusions.

Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes

Background

There has been growing interest in the NHS over recent years in the use of enhanced recovery programmes for elective surgery to deliver productivity gains through reduced length of stay, fewer postoperative complications, reduced readmissions and improved patient outcomes.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings. To identify and critically describe key factors associated with successful adoption, implementation and sustainability of enhanced recovery programmes in UK settings. To summarise existing knowledge about patient experience of enhanced recovery programmes in UK settings.

Data sources

Eight databases, including Database of Abstracts of Reviews and Effects, International Prospective of Systematic Reviews, NHS Economic Evaluation Database and MEDLINE, were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines and reference lists of retrieved articles were scanned to identify additional studies.

Review methods

Systematic reviews, randomised controlled trials (RCTs), economic evaluations, and UK NHS cost analysis studies were included if they evaluated the impact of enhanced recovery programmes on any health- and cost-related outcomes. Eligible studies included patients undergoing elective surgery in an acute hospital setting. Implementation case studies and surveys of patient experience in a UK setting were also eligible for inclusion. Quality assessment of systematic reviews, RCTs and economic evaluations was based on existing Centre for Reviews and Dissemination processes. All stages of the review process were performed by one researcher and checked by a second with discrepancies resolved by consensus. The type and range of evidence precluded meta-analysis and we therefore performed a narrative synthesis, differentiating between clinical effectiveness and cost-effectiveness, implementation case studies and evidence on patient experience.

Results

Seventeen systematic reviews of varying quality were included in this report. Twelve additional RCTs were included; all were considered at high risk of bias. Most of the evidence focused on colorectal surgery. Fourteen innovation case studies and 15 implementation case studies undertaken in NHS settings were identified and provide descriptions of factors critical to the success of an enhanced recovery programme. Ten relevant economic evaluations were identified evaluating costs and outcomes over short time horizons. Despite the plethora of studies, robust evidence was sparse. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5–3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reported reductions in length of stay reflecting the limited evidence identified.

Limitations

Findings relating to other clinical outcomes, cost-effectiveness, implementation and patient experience were hampered by a lack of robust evidence and poor reporting.

Conclusions

There is consistent, albeit limited, evidence that enhanced recovery programmes may reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes can realise reductions and cost savings will depend on length of stays achieved under their existing care pathway. RCTs comparing an enhanced recovery programme with conventional care continue to be conducted and published. Further single-centre RCTs of this kind are not a priority. Rather, what is needed is improved collection and reporting of how enhanced recovery programmes are implemented, resourced and experienced in NHS settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Predictors of hospital stay following laparoscopic gastric bypass: analysis of 9,593 patients from the National Surgical Quality Improvement Program

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.

Association of nursing-documented ambulation with length of stay following total laparoscopic hysterectomy for benign gynecologic disease

Objective

The objective was to examine the association of postoperative physical activity with length of stay in patients who received total laparoscopic hysterectomy for benign gynecologic disease.

Methods

The case group was composed of 70 patients who entered a critical pathway for elective total laparoscopic hysterectomy from 2009 to 2012 and were discharged behind schedule. The control group was selected from patients who were discharged on schedule, and matched to cases using 1:3 ratio propensity score matching. We compared the number of nursing-documented ambulation of the case group with that of control group.

Results

Year of surgery, age, body mass index, endometriosis, systemic disease, previous abdominal surgery and current medication were well balanced between case and control groups. The number of patients with nursing-documented ambulation in case group (19%) was not different from that in control group (11%).

Conclusion

Postoperative physical activity measured by nursing-documented ambulation was not associated with length of stay in patients who underwent an elective total laparoscopic hysterectomy for benign gynecologic diseases.

Enhanced recovery pathways as a way to reduce surgical morbidity

PURPOSE OF REVIEW

The aim of this review is to summarize important publications in enhanced recovery during 2010-2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome.

RECENT FINDINGS

An expanding evidence base of clinical trials and implementation evaluations supports the effectiveness of enhanced recovery programmes in improving outcome following major elective surgery. The majority of this literature derives from the study of patients undergoing colorectal surgery, but increasingly enhanced recovery is spreading to other surgical specialties. The combination of reduced length of hospital stay (a surrogate for morbidity) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery. Inconsistency in morbidity reporting limits the value of pooling data between studies, but within study comparisons in general support this conclusion. Patients adhering to an enhanced recovery programme return to normal function faster than those following traditional care pathways.

SUMMARY

Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.

Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Postoperative pain management remains a significant challenge after abdominal surgery.

OBJECTIVE

The aim of this meta-analysis was to evaluate the efficacy of systemic lidocaine for postoperative pain management and recovery after abdominal surgery.

DATA SOURCE

Data were derived from Medline (1966-2010), CINAHL, The Cochrane Central Register of Controlled Trials, and Scopus.

STUDY SELECTION

Randomized controlled trials of systemic administration of lidocaine for postoperative analgesia and recovery after abdominal surgery in adults, ie, >18 years, were considered.

INTERVENTIONS

Combined data were analyzed with use of a random-effects model.

MAIN OUTCOMES MEASURES

Data on opioid consumption, postoperative pain intensity, opioid-related side effects, time to first flatus, time to first bowel movement, and length of hospital stay were extracted.

RESULTS

Twenty-one trials comparing systemic lidocaine with placebo or blank control for postoperative analgesia and recovery after abdominal surgery were included in this meta-analysis. Weighted mean difference for cumulative analgesic opioid (morphine) consumption 48 hours after surgery was -7.04 mg (95% CI: -10.40, -3.68, I2= 46.1%).Systemic lidocaine also significantly reduced postoperative pain intensity(visual analog scale, 0-100 mm) 6 hours after surgery at rest (weighted mean difference: -8.07 mm (95% CI: -14.69, -1.49); I2 = 90.6%) and during activity (weighted mean difference: -10.56 mm (95% CI: -16.89, -4.23), I2 = 82%). The time to first flatus and bowel movement was significantly shortened with lidocaine intervention by 6.92 hours (95% CI: -9.21, -4.63, I2 = 62.8%) and 11.74 hours (95% CI:-16.97, -6.51, I2 = 0). Moreover, systemic lidocaine also reduced hospital length of stay following the open procedure (weighted mean difference: -0.71 days (95% CI: -1.35, -0.07); I2 = 37.3%).

LIMITATIONS

Heterogeneity of study results is the main limitation of this meta-analysis.

CONCLUSION

Perioperative systemic lidocaine may be a useful adjunct for postoperative pain management by decreasing postoperative pain intensity, reducing opioid consumption, facilitating GI function, and shortening length of hospital stay.