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Fleurent-Grégoire C, Burgess N, Denehy L, Edbrooke L, Engel D, Testa GD, Fiore JF, McIsaac DI, Chevalier S, Moore J, Grocott MP, Copeland R, Levett D, Scheede-Bergdahl C, Gillis C. Outcomes reported in randomised trials of surgical prehabilitation: a scoping review. Br J Anaesth 2024; 133:42-57. [PMID: 38570300 PMCID: PMC11213997 DOI: 10.1016/j.bja.2024.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.
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Affiliation(s)
- Chloé Fleurent-Grégoire
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Nicola Burgess
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Lara Edbrooke
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stéphanie Chevalier
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC, Canada
| | - John Moore
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michael P Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Robert Copeland
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Denny Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill Research, Centre for Physical Activity & Health, McGill University, Montreal, QC, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Department of Surgery, McGill University, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada.
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Jolly S, Paliwal S, Gadepalli A, Chaudhary S, Bhagat H, Avitsian R. Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review. J Neurosurg Anesthesiol 2024; 36:201-210. [PMID: 38011868 DOI: 10.1097/ana.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.
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Affiliation(s)
- Sagar Jolly
- Department of General Anesthesiology, Cleveland Clinic, OH
| | | | - Aditya Gadepalli
- Department of Anaesthetics and Intensive Care, Royal Free London NHS Foundation Trust, London, UK
| | - Sheena Chaudhary
- Department of Neuroanesthesia and Critical Care, Fortis Memorial Research Institute, Gurugram, HR, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, OH
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Thierry G, Beck F, Hardy PY, Kaba A, Blanjean A, Vandermeulen M, Honoré P, Joris J, Bonhomme V, Detry O. Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study. Surg Endosc 2024; 38:3253-3262. [PMID: 38653900 DOI: 10.1007/s00464-024-10796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP. MATERIALS AND METHODS Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined. RESULTS Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001). CONCLUSIONS The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.
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Affiliation(s)
- Gabriel Thierry
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium.
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France.
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium.
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium.
| | - Florian Beck
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Pierre-Yves Hardy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Abdourahamane Kaba
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Arielle Blanjean
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Morgan Vandermeulen
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
| | - Pierre Honoré
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
| | - Jean Joris
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
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Tankel J, Sticca G, Kammili A, Dehghani M, Sakalla R, Ahmed N, Meng A, Najmeh S, Spicer J, Cools-Lartigue J, Ferri L, Mueller C. ERAS following Gastrectomy for Octo- and Nonagenarians: A Single-Center Retrospective Analysis. J Laparoendosc Adv Surg Tech A 2024; 34:484-489. [PMID: 38770682 DOI: 10.1089/lap.2024.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background: The safety and efficacy of enhanced recovery after surgery (ERAS) following elective gastrectomy for gastric cancer in patients >80 years of age are not well described. The aim of this study was to explore whether an ERAS protocol following gastrectomy in this age group can be safely implemented and reduce postoperative length of stay. Methods: A retrospective, single-center analysis was performed. All patients >80 years of age with gastric cancer undergoing elective subtotal and total gastrectomy between January 2010 and December 2021 were identified. With the implementation of an ERAS protocol in January 2016, patients treated beforehand were allocated to Group A (pre-ERAS) and Group B (ERAS). The length of stay, incidence of postoperative complications and representation/readmission to the hospital were compared between the groups. Results: Of the 221 patients identified, 56 met the inclusion criteria with 22 patients (39.3%) allocated to Group A and 34 patients (60.7%) to Group B. There were no differences with regard to the type of resection and surgical approach. Length of stay was shorter in Group B (5 days, range 2-27 versus 10 days, 3-109, P = .040). A trend toward more discharges by postoperative day 3 was noted among patients in Group B (7/34, 20.6% versus 2/22, 9.1%, P = .253). There were no differences in the incidence of postoperative complications or readmission hospital between the groups. Conclusion: Among patients >80 years of age, ERAS following gastrectomy for cancer is associated with a reduced length of stay and can be safely implemented.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Giancarlo Sticca
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Anitha Kammili
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Mehrnoush Dehghani
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rawan Sakalla
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Nabeel Ahmed
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Andrew Meng
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Gianotti L, Nespoli L, Sandini M. Pharmaconutrition: Which substrates? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106798. [PMID: 36526494 DOI: 10.1016/j.ejso.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/10/2022] [Indexed: 12/14/2022]
Abstract
With the term "pharmaconutrition" or "immunonutrition" is intended the use of specific nutritional substrates having the ability of modulating specific mechanisms involved in several immune and inflammatory pathways. To achieve these goals, these substrates have to be administered with over physiologic dose. Glutamine and omega-3 polyunsaturated fatty acids, used as single substrate, did not show clear clinical advantages on solid endpoints such as postoperative complications. Despite several multiple substrate enteral feeds are available on the market, very few of them have been tested in randomized clinical trial to prove efficacy. The most extensive investigated formulation is a combination of arginine, omega-3 fatty acids, ribonucleic acid with or without glutamine. Several meta-analyses of randomized clinical trials have been conducted to compare the effects of enteral immunonutrition with control diets on post-surgical morbidity. The results consistently showed that the use of enteral multiple substrate formulas significantly reduced infectious complications and duration of hospitalization. In a more contemporary view, pharmaconutrition should be tested more accurately in the contest of enhanced recovery programs, during neoadjuvant chemotherapy, and in the prehabilitation setting.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, IRCCS San Gerardo Hospital, Monza, Italy.
| | - Luca Nespoli
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, IRCCS San Gerardo Hospital, Monza, Italy
| | - Marta Sandini
- Surgical Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Azimuddin A, Tzeng CWD, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Newhook TE, Kim MP, Ikoma N, Snyder RA, Lee JE, Perrier ND, Katz MH, Maxwell JE. Postoperative Global Period Cost Reduction Using 3 Successive Risk-Stratified Pancreatectomy Clinical Pathways. J Am Coll Surg 2024; 238:451-459. [PMID: 38180055 DOI: 10.1097/xcs.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND We hypothesized that iterative revisions of our original 2016 risk-stratified pancreatectomy clinical pathways would be associated with decreased 90-day perioperative costs. STUDY DESIGN From a single-institution retrospective cohort study of consecutive patients with 3 iterations: "version 1" (V1) (October 2016 to January 2019), V2 (February 2019 to October 2020), and V3 (November 2020 to February 2022), institutional data were aggregated using revenue codes and adjusted to constant 2022-dollar value. Grand total perioperative costs (primary endpoint) were the sum of pancreatectomy, inpatient care, readmission, and 90-day global outpatient care. Proprietary hospital-based costs were converted to ratios using the mean cost of all hospital operations as the denominator. RESULTS Of 814 patients, pathway V1 included 363, V2 229, and V3 222 patients. Accordion Grade 3+ complications decreased with each iteration (V1: 28.4%, V2: 22.7%, and V3: 15.3%). Median length of stay decreased (V1: 6 days, interquartile range [IQR] 5 to 8; V2: 5 [IQR 4 to 6]; and V3: 5 [IQR 4 to 6]) without an increase in readmissions. Ninety-day global perioperative costs decreased by 32% (V1 cost ratio 12.6, V2 10.9, and V3 8.6). Reduction of the index hospitalization cost was associated with the greatest savings (-31%: 9.4, 8.3, and 6.5). Outpatient care costs decreased consistently (1.58, 1.41, and 1.04). When combining readmission and all outpatient costs, total "postdischarge" costs decreased (3.17, 2.59, and 2.13). Component costs of the index hospitalization that were associated with the greatest savings were room or board costs (-55%: 1.74, 1.14, and 0.79) and pharmacy costs (-61%: 2.20, 1.61, and 0.87; all p < 0.001). CONCLUSIONS Three iterative risk-stratified pancreatectomy clinical pathway refinements were associated with a 32% global period cost savings, driven by reduced index hospitalization costs. This successful learning health system model could be externally validated at other institutions performing abdominal cancer surgery.
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Affiliation(s)
- Ahad Azimuddin
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
- Texas A&M School of Medicine, Houston, TX (Azimuddin)
| | - Ching-Wei D Tzeng
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Laura R Prakash
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Morgan L Bruno
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Elsa M Arvide
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Whitney L Dewhurst
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Timothy E Newhook
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Michael P Kim
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Naruhiko Ikoma
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Rebecca A Snyder
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jeffrey E Lee
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Nancy D Perrier
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Matthew Hg Katz
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jessica E Maxwell
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
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Yamamoto T, Shinozaki T, Nishiya Y, Okano W, Tomioka T, Matsuura K, Furuse K, Oshima A, Higashino T, Hayashi R. Early enteral nutrition and mobilization following head and neck surgery with free flap reconstruction. Jpn J Clin Oncol 2024:hyae043. [PMID: 38555498 DOI: 10.1093/jjco/hyae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Perioperative management methods that reduce surgery-associated invasiveness and improve the quality of postoperative recovery are being promoted as enhanced recovery after surgery programs in various areas. Early enteral nutrition and mobilization are essential elements for enhanced recovery after surgery; however, their safety and feasibility are unclear in head and neck surgery with free tissue transfer reconstruction. This study aimed to clarify these uncertainties. METHODS This is a retrospective before-after study. From 2018 to 2022, 187 and 173 patients received conventional management on or before April 2020 and early management on or after May 2020, respectively. The conventional management and early management groups received enteral nutrition and mobilization on postoperative days 2 and 1, respectively. The primary outcome for safety assessment was the incidence of complications. The secondary outcome was the compliance rate of conventional management or early management for feasibility assessment and the length of hospital stay. RESULTS The clinical tumour-node-metastasis stage and American Society of Anesthesiologists physical status showed significant differences between the groups. In multivariable analysis, the early management group demonstrated a significantly lower incidence of treatment-required complication classified Clavien-Dindo Grade 2 and above (odds ratio = 0.57; 95% confidence interval = 0.31-0.92) and lower wound infection (odds ratio = 0.53; 95% confidence interval = 0.31-0.92). The early management group had lower compliance rate than the conventional management group; however, no statistically significant difference was observed (79.8% vs. 85.0%, P = 0.21). CONCLUSION Early management is safe and feasible following head and neck surgery with free tissue transfer reconstruction. It could reduce the complication rate and is considered a useful postoperative management method.
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Affiliation(s)
- Takuya Yamamoto
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takeshi Shinozaki
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yukio Nishiya
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Wataru Okano
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Toshifumi Tomioka
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kiichi Furuse
- Department of Plastic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Azusa Oshima
- Department of Plastic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuya Higashino
- Department of Plastic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Ryuichi Hayashi
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Hao Y, Zhao Q, Jiang K, Feng X, Ma Y, Zhang J, Han X, Ji G, Dong H, Nie H. Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy. BMC Anesthesiol 2024; 24:110. [PMID: 38519945 PMCID: PMC10958831 DOI: 10.1186/s12871-024-02433-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/26/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVE The current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG). EXPOSURES Laparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not. MAIN OUTCOMES AND MEASURES The primary study outcome was a composite outcome called 'optimal postoperative recovery' with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics. RESULTS A total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21-3.34) and stepwise regression (OR 2.07, 95% CI 1.25-3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery. CONCLUSIONS AND RELEVANCE Patients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.
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Affiliation(s)
- Yiming Hao
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Qingchuan Zhao
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kun Jiang
- Department of Digital Center, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiangying Feng
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yumei Ma
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | | | - Xi'an Han
- The Unimed Scientific Inc, Wu Xi, China
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Hailong Dong
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Huang Nie
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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9
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Borges RB, Caumo W, Bavaresco C, Stefani LPC, Santos VSD, Castro SMDJ. The brief measure of preoperative emotional stress screens preoperative maladaptive psychological features and predicts postoperative opioid use: an observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744425. [PMID: 36894010 DOI: 10.1016/j.bjane.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The Brief Measure of Preoperative Emotional Stress (B-MEPS) is a suitable screening tool for Preoperative Emotional Stress (PES). However, personalized decision-making demands practical interpretation of the refined version of B-MEPS. Thus, we propose and validate cut-off points on the B-MEPS to classify PES. Also, we assessed if the cut-off points screened preoperative maladaptive psychological features and predicted postoperative opioid use. METHODS This observational study comprises samples of two other primary studies, with 1009 and 233 individuals, respectively. The latent class analysis derived emotional stress subgroups using B-MEPS items. We compared membership with the B-MEPS score through the Youden index. Concurrent criterion validity of the cut-off points was performed with the severity of preoperative depressive symptoms, pain catastrophizing, central sensitization, and sleep quality. Predictive criterion validity was performed with opioid use after surgery. RESULTS We chose a model with three classes labeled mild, moderate, and severe. The Youden index points -0.1663 and 0.7614 of the B-MEPS score classify individuals, in the severe class, with a sensitivity of 85.7% (80.1%-90.3%) and specificity of 93.5% (91.5-95.1%). The cut-off points of the B-MEPS score have satisfactory concurrent and predictive criterion validity. CONCLUSIONS These findings showed that the preoperative emotional stress index on the B-MEPS offers suitable sensitivity and specificity for discriminating the severity of preoperative psychological stress. They provide a simple tool to identify patients prone to severe PES related to maladaptive psychological features, which might influence the perception of pain and analgesic opioid use in the postoperative period.
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Affiliation(s)
- Rogério Boff Borges
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brazil; Hospital das Clínicas de Porto Alegre, Unidade de Bioestatística, Diretoria de Pesquisa, Porto Alegre, RS, Brazil.
| | - Wolnei Caumo
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Ciências Médicas, Porto Alegre, RS, Brazil; Hospital das Clínicas de Porto Alegre, Laboratório de Dor e Neuromodulação, Porto Alegre, RS, Brazil
| | - Caroline Bavaresco
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Ciências Médicas, Porto Alegre, RS, Brazil
| | - Luciana Paula Cadore Stefani
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Ciências Médicas, Porto Alegre, RS, Brazil
| | | | - Stela Maris de Jezus Castro
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brazil; Hospital das Clínicas de Porto Alegre, Unidade de Bioestatística, Diretoria de Pesquisa, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul, Instituto de Matemática e Estatística, Departamento de Estatística, Porto Alegre, RS, Brazil
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10
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Porserud A, Karlsson P, Nygren-Bonnier M, Aly M, Hagströmer M. The feasibility of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer, prior to the CanMoRe trial. Pilot Feasibility Stud 2024; 10:12. [PMID: 38254174 PMCID: PMC10802056 DOI: 10.1186/s40814-024-01443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/02/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Complications after radical cystectomy for urinary bladder cancer are common. Physical activity after surgery is thought to reduce complications. However, patients with urinary bladder cancer have low levels of physical activity, and interventions supporting physical exercise are needed. This study aimed to evaluate the feasibility of a physical exercise intervention in primary health care. One of the aims of the larger clinical trial will be to reduce complications. METHODS Patients with urinary bladder cancer and who were scheduled for a robotic-assisted radical cystectomy were recruited from Karolinska University Hospital, between February and May 2019. The patients had to be mobile, understand Swedish, and live in Stockholm. The exercise programme was conducted at one primary health care setting over 12 weeks. The exercise programme included supervised aerobic and strengthening exercises, which were performed twice a week, as well as daily walks. Feasibility was measured with process feasibility, including eligibility criteria, adherence, and acceptability, and scientific feasibility, including the ability of outcomes to indicate change, safety, and progression in the exercise programme. RESULTS Ten patients with a median age of 70 years (min 53-max 86) were included. Adherence to all parts of the intervention was not feasible because of patients' postoperative complications, resulting in dropouts. For the patients who took part in the exercise programme, adherence and acceptability for the exercise period were feasible, but the 6-min walk test was not feasible at discharge from the hospital. Physiotherapists in the primary health care setting perceived the process as feasible. Moreover, the ability of outcomes to indicate change and progression in the exercise programme was feasible, meanwhile no adverse events were registered. CONCLUSIONS The exercise intervention was feasible for the patients that took part in the exercise programme, with respect to safety and progression through the exercise programme. Furthermore, this study suggests that some improvements needed to be implemented in the process, prior to the upcoming randomised controlled trial.
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Affiliation(s)
- Andrea Porserud
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden.
- Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Patrik Karlsson
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden
- Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Malin Nygren-Bonnier
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden
- Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Markus Aly
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77, Stockholm, Sweden
- Patient Area Pelvic Cancer, Cancer Theme, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Maria Hagströmer
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden
- Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Academic Primary Health Care Centre, 113 65, Stockholm, Region Stockholm, Sweden
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11
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Lehane D, Geiger J, Kedwai B, Zottola Z, Newhall K, Mix D, Doyle A, Stoner M. Long-term value in open and endovascular repair of chronic mesenteric ischemia. J Vasc Surg 2024; 79:55-61. [PMID: 37709177 DOI: 10.1016/j.jvs.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. METHODS Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. RESULTS From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively. CONCLUSIONS Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.
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Affiliation(s)
- Daniel Lehane
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Joshua Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Baqir Kedwai
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Zachary Zottola
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karina Newhall
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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12
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Olsén MF, Andersson T, Nouh MA, Johnson E, Block L, Vakk M, Wennerblom J. Development of and adherence to an ERAS ® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study. Scand J Surg 2023; 112:235-245. [PMID: 37461804 DOI: 10.1177/14574969231186274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND OBJECTIVE There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery. METHODS Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire. RESULTS The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups. CONCLUSION The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.
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Affiliation(s)
- Monika Fagevik Olsén
- Department of Physical Therapy, Sahlgrenska University Hospital S-413 45 Gothenburg Sweden
| | - Thomas Andersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Micheline Al Nouh
- Department of Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Johnson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - My Vakk
- Department of Clinical Nutrition, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Schaaf S, Weber C, Güsgen C, Schwab R, Willms A. [Physical Strain after Abdominal Surgery - Results of a Patient Survey]. Zentralbl Chir 2023; 148:516-523. [PMID: 33540461 DOI: 10.1055/a-1346-0274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Incision hernias are common complications after abdominal surgery and affect the recommendations on postoperative physical strain, as it is thought that excessively early strain causes incisional hernias. However, there is no evidence to justify this. This study evaluates the effect of postoperative strain on the risk of incisional hernia. MATERIALS AND METHODS Patients with a laparoscopy (LS) or laparotomy (LT) were asked to complete a questionnaire on postoperative strain, complaints and quality of life. Patients with hernia surgery, or open abdomen therapy for complicated courses (Clavien-Dindo > III) were excluded. RESULTS 393 patients completed the questionnaire (43.6%). 274 were LS and 128 LT. The incidence of incisional hernias was 5.2% (LS) and 18.0% (LT, p = 0.001). Incisional hernia patients were younger and more commonly males. 30.5% of incisional hernia patients did not return to normal physical strain postoperatively. Abdominal binders did not affect the hernia rate. The incisional hernia patients showed decreased quality of life scores in both mental and physical domains. CONCLUSION Early postoperative physical strain was not a risk factor for incisional hernia development in this study. However, prospective studies are needed to create necessary evidence to recommend earlier postoperative return to normal physical strain.
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Affiliation(s)
- Sebastian Schaaf
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Carsten Weber
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Christoph Güsgen
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Robert Schwab
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Arnulf Willms
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
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14
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Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, Berrevoet F, de Beaux AC, East B, Henriksen NA, Klugar M, Langaufová A, Miserez M, Morales-Conde S, Montgomery A, Pettersson PK, Reinpold W, Renard Y, Slezáková S, Whitehead-Clarke T, Stabilini C. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg 2023; 110:1732-1768. [PMID: 37727928 PMCID: PMC10638550 DOI: 10.1093/bjs/znad284] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- David L Sanders
- Academic Department of Abdominal Wall Surgery, Royal Devon University
Foundation Healthcare Trust, North Devon District Hospital,
Barnstaple, UK
- University of Exeter Medical School,
Exeter, UK
| | - Maciej M Pawlak
- Academic Department of Abdominal Wall Surgery, Royal Devon University
Foundation Healthcare Trust, North Devon District Hospital,
Barnstaple, UK
- University of Exeter Medical School,
Exeter, UK
| | - Maarten P Simons
- Department of Surgery, OLVG Hospital Amsterdam,
Amsterdam, The
Netherlands
| | - Theo Aufenacker
- Department of Surgery, Rijnstate Hospital Arnhem,
Arnhem, The Netherlands
| | - Andrea Balla
- IRCCS San Raffaele Scientific Institute,
Milan, Italy
| | - Cigdem Berger
- Hamburg Hernia Centre, Department of Hernia and Abdominal Wall Surgery,
Helios Mariahilf Hospital Hamburg, Teaching Hospital of the University of Hamburg,
Hamburg, Germany
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, Ghent
University Hospital, Ghent, Belgium
| | | | - Barbora East
- 3rd Department of Surgery at 1st Medical Faculty of Charles University,
Motol University Hospital, Prague, Czech Republic
| | - Nadia A Henriksen
- Department of Gastrointestinal and Hepatic Diseases, University of
Copenhagen, Herlev Hospital, Copenhagen, Denmark
| | - Miloslav Klugar
- The Czech National Centre for Evidence-Based Healthcare and Knowledge
Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk
University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of
Medicine, Masaryk University, Brno, Czech Republic
| | - Alena Langaufová
- Department of Health Sciences, Faculty of Medicine, Masaryk
University, Brno, Czech
Republic
| | - Marc Miserez
- Department of Abdominal Surgery, University Hospital Gasthuisberg, KU
Leuven, Leuven, Belgium
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and
Digestive Surgery, University Hospital Virgen del Rocio, University of
Sevilla, Sevilla, Spain
| | - Agneta Montgomery
- Department of Surgery, Skåne University Hospital,
Malmö, Sweden
- Department of Clinical Sciences, Malmö Faculty of Medicine, Lund
University, Lund, Sweden
| | - Patrik K Pettersson
- Department of Surgery, Skåne University Hospital,
Malmö, Sweden
- Department of Clinical Sciences, Malmö Faculty of Medicine, Lund
University, Lund, Sweden
| | - Wolfgang Reinpold
- Hamburg Hernia Centre, Department of Hernia and Abdominal Wall Surgery,
Helios Mariahilf Hospital Hamburg, Teaching Hospital of the University of Hamburg,
Hamburg, Germany
| | - Yohann Renard
- Reims Champagne-Ardennes, Department of General, Digestive and Endocrine
Surgery, Robert Debré University Hospital, Reims,
France
| | - Simona Slezáková
- The Czech National Centre for Evidence-Based Healthcare and Knowledge
Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk
University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of
Medicine, Masaryk University, Brno, Czech Republic
| | - Thomas Whitehead-Clarke
- Centre for 3D Models of Health and Disease, Division of Surgery and
Interventional Science, University College London,
London, UK
| | - Cesare Stabilini
- Department of Surgery, University of Genoa,
Genoa, Italy
- Policlinico San Martino, IRCCS, Genoa,
Italy
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15
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Geraedts TCM, Weijs TJ, Berkelmans GHK, Fransen LFC, Kouwenhoven EA, van Det MJ, Nilsson M, Lagarde SM, van Hillegersberg R, Markar SR, Nieuwenhuijzen GAP, Luyer MDP. Long-Term Survival Associated with Direct Oral Feeding Following Minimally Invasive Esophagectomy: Results from a Randomized Controlled Trial (NUTRIENT II). Cancers (Basel) 2023; 15:4856. [PMID: 37835550 PMCID: PMC10571988 DOI: 10.3390/cancers15194856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023] Open
Abstract
Advancements in perioperative care have improved postoperative morbidity and recovery after esophagectomy. The direct start of oral intake can also enhance short-term outcomes following minimally invasive Ivor Lewis esophagectomy (MIE-IL). Subsequently, short-term outcomes may affect long-term survival. This planned sub-study of the NUTRIENT II trial, a multicenter randomized controlled trial, investigated the long-term survival of direct versus delayed oral feeding following MIE-IL. The outcomes included 3- and 5-year overall survival (OS) and disease-free survival (DFS), and the influence of complications and caloric intake on OS. After excluding cases of 90-day mortality, 145 participants were analyzed. Of these, 63 patients (43.4%) received direct oral feeding. At 3 years, OS was significantly better in the direct oral feeding group (p = 0.027), but not at 5 years (p = 0.115). Moreover, 5-year DFS was significantly better in the direct oral feeding group (p = 0.047) and a trend towards improved DFS was shown at 3 years (p = 0.079). Postoperative complications and caloric intake on day 5 did not impact OS. The results of this study show a tendency of improved 3-year OS and 5-year DFS, suggesting a potential long-term survival benefit in patients receiving direct oral feeding after esophagectomy. However, the findings should be further explored in larger future trials.
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Affiliation(s)
- Tessa C. M. Geraedts
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Teus J. Weijs
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Gijs H. K. Berkelmans
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Laura F. C. Fransen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Ewout A. Kouwenhoven
- Department of Surgery, ZGT Hospital Group Twente, 7609 PP Almelo, The Netherlands; (E.A.K.); (M.J.v.D.)
| | - Marc J. van Det
- Department of Surgery, ZGT Hospital Group Twente, 7609 PP Almelo, The Netherlands; (E.A.K.); (M.J.v.D.)
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden;
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Sjoerd M. Lagarde
- Department of Surgery, Eramus Medical Center, 3015 CN Rotterdam, The Netherlands;
| | | | - Sheraz R. Markar
- Nuffield Department of Surgery, University of Oxford, Oxford OX3 9DU, UK;
| | - Grard A. P. Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
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16
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Frankel L, Ardeljan AD, Rashid A, Nair A, Takabe K, Rashid OM. Improving Value in Colorectal Cancer Care: An Economic Analysis of Enhanced Recovery Protocols at a Community Hospital. World J Oncol 2023; 14:401-405. [PMID: 37869240 PMCID: PMC10588494 DOI: 10.14740/wjon1580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/17/2023] [Indexed: 10/24/2023] Open
Abstract
Background Enhanced recovery protocols (ERPs) have been shown to improve the outcomes of gastrointestinal cancer care, leading to reduced morbidity of gastrointestinal treatment and reduced delays in systemic therapy. ERP implementation has also previously shown a reduction in length of stay (LOS) without changing the readmission rate; however, the economic cost associated with these measures has not yet been quantified. The aim of this study was to evaluate the economic costs of ERP implementation for colorectal cancer at a community hospital. Methods The Diagnostic Related Group (DRG) codes were used to assess costs associated with the hospitalizations of cases in the ERP versus non-ERP groups. The American Hospital Association (AHA) Annual Survey from 1999 to 2015 was used to provide the expenses per day for inpatient hospitalization in the United States. Postoperative LOS, average healthcare costs, and postoperative complications between ERP-protocol and non-ERP protocol groups were analyzed using analysis of variance (ANOVA) and independent t-tests. Results The AHA survey estimated that $2,265 was incurred per day for non-profit hospitals in Florida and $2,346 was incurred per day for the United States. For all DRG codes, the ERP-participating group was associated with a shorter LOS and reduced health care costs. LOS-associated cost was compared between ERP and non-ERP groups: for DRG 329, the total savings was $162,118.8 (n = 12 non-ERP versus n = 8 ERP, P = 4.39 × 10-18); for DRG 330, $314,552.64 (n = 36 non-ERP versus n = 24 ERP, P = 2.72 × 10-22); and for DRG 331, $89,302.73 (n = 11 non-ERP versus n = 23 for ERP, P = 4.19 × 10-20). Conclusions The implementation of an ERP protocol for colorectal cancer was associated with significantly reduced costs in a community hospital.
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Affiliation(s)
- Lexi Frankel
- Department of Surgery, Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
- Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Amalia D. Ardeljan
- Department of Surgery, Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Ali Rashid
- Department of Surgery, Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
| | - Abhishek Nair
- Rapides Regional Medical Center, Alexandria, LA, USA
| | - Kazuaki Takabe
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY, USA
| | - Omar M. Rashid
- Department of Surgery, Michael and Dianne Biennes Comprehensive Cancer Center, Holy Cross Health, Fort Lauderdale, FL, USA
- Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
- University of Miami, Leonard Miami School of Medicine, Miami, FL, USA
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgical Oncology, Broward Health, Fort Lauderdale, FL, USA
- TopLine MD Alliance, Fort Lauderdale, FL, USA
- Department of Surgical Oncology, Memorial Health, Pembroke Pines, FL, USA
- Department of Surgical Oncology, Delray Medical Center, Delray, FL, USA
- Complex General Surgical Oncology, General & Robotic Surgery, TopLine MD Alliance, Fort Lauderdale, FL 33308, USA
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17
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Nguyen Y, Fernandez L, Trainer B, McNulty M, Kazior MR. Decreased Length of Stay and Opioid Usage After Liver Cancer Surgery With Enhanced Recovery Pathway Implementation. Qual Manag Health Care 2023; 32:217-221. [PMID: 36913769 DOI: 10.1097/qmh.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) pathways are associated with better postoperative recovery; however, evidence is lacking in liver cancer surgery. This study aimed to evaluate the impact of an ERAS pathway in US veterans undergoing liver cancer surgery. METHODS We initiated an ERAS pathway for liver cancer surgery with preoperative, intraoperative, and postoperative interventions, which included a novel regional anesthesia technique, erector spinae plane block, for multimodal analgesia management. A retrospective quality improvement study was conducted with patients undergoing elective open hepatectomy or microwave ablation of liver tumors before and after ERAS pathway implementation. RESULTS With 24 patients in the post-ERAS group and 23 patients in the pre-ERAS group, we found a significant decreased length of stay in the ERAS group (4.1 days ± 3.9) compared with traditional care (8.6 days ± 7.1, P = .01) and decreased perioperative opioid consumption including intraoperative opioids (post-ERAS 49.8 mg ± 28.5 vs pre-ERAS 98 mg ± 42.3, P = 4.1E-5), postoperative opioids (post-ERAS 65.3 mg ± 59.9 vs pre-ERAS 175.7 mg ± 210.6, P = .018), and patient-controlled analgesia requirements (post-ERAS 0% vs pre-ERAS 50%, P < .001). CONCLUSION The implementation of ERAS for liver cancer surgery in our veteran population translates into decreased length of stay and perioperative opioid consumption. Although this study is limited as a quality improvement project implemented at one institution with a small sample size, our results are clinically and statistically significant and sufficient to warrant further investigation into the efficacy of ERAS as the surgical needs of the US veteran population increase.
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Affiliation(s)
- Yvonne Nguyen
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond (Drs Nguyen and Kazior); and Departments of Surgery (Dr Fernandez and Ms McNulty) and Anesthesiology (Drs Trainer and Kazior), Central Virginia VA Medical Center, Richmond
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18
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Efune PN, Hoyt MJ, Saynhalath R, Ahn C, Pearsall MF, Khan UH, Feehan T, Desai DM, Szmuk P. Intraoperative fluid administration volumes during pediatric liver transplantation and postoperative outcomes: A multicenter analysis. Paediatr Anaesth 2023; 33:754-764. [PMID: 37326251 DOI: 10.1111/pan.14710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Fluid administration is an important aspect of the management of children undergoing liver transplantation and may impact postoperative outcomes. Our aim was to evaluate the association between volume of intraoperative fluid administration and our primary outcome, the duration of postoperative mechanical ventilation following pediatric liver transplantation. Secondary outcomes included intensive care unit length of stay and hospital length of stay. METHODS We conducted a multicenter, retrospective cohort study using electronic data from three major pediatric liver transplant centers. Intraoperative fluid administration was indexed to weight and duration of anesthesia. Univariate and stepwise linear regression analyses were conducted. RESULTS Among 286 successful pediatric liver transplants, the median duration of postoperative mechanical ventilation was 10.8 h (IQR 0.0, 35.4), the median intensive care unit length of stay was 4.3 days (IQR 2.7, 6.8), and the median hospital length of stay was 13.6 days (9.8, 21.1). Univariate linear regression showed a weak correlation between intraoperative fluids and duration of ventilation (r2 = .037, p = .001). Following stepwise linear regression, intraoperative fluid administration remained weakly correlated (r2 = .161, p = .04) with duration of postoperative ventilation. The following variables were also independently correlated with duration of ventilation: center (Riley Children's Health versus Children's Health Dallas, p = .001), and open abdominal incision after transplant (p = .001). DISCUSSION The amount of intraoperative fluid administration is correlated with duration of postoperative mechanical ventilation in children undergoing liver transplantation, however, it does not seem to be a strong factor. CONCLUSIONS Other modifiable factors should be sought which may lead to improved postoperative outcomes in this highly vulnerable patient population.
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Affiliation(s)
- Proshad N Efune
- Division of Pediatric Anesthesia, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Matthew J Hoyt
- Department of Anesthesiology, Riley Children's Health at Indiana University Health, Indianapolis, Indiana, USA
| | - Rita Saynhalath
- Division of Pediatric Anesthesia, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Chul Ahn
- Department of Populations and Data Sciences & Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Matthew F Pearsall
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Thomas Feehan
- Department of Anesthesiology, Riley Children's Health at Indiana University Health, Indianapolis, Indiana, USA
| | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter Szmuk
- Division of Pediatric Anesthesia, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
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Zhou J, Liu X, Guo X, Yang X, Ma X, Liu W. Grip strength is an important predictor for nutritional risk and early postoperative ambulation in gastrointestinal tumors undergoing laparoscopic surgery: a prospective multicenter clinical study. World J Surg Oncol 2023; 21:273. [PMID: 37644549 PMCID: PMC10466861 DOI: 10.1186/s12957-023-03163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Using grip strength as a predictor of nutritional risk and early ambulation for gastrointestinal tumor surgery and determining its critical value have not been reported. This study was designed to explore the influencing factors of early postoperative ambulation ability for patients with gastrointestinal tumors who underwent laparoscopic surgery. METHODS Four-hundred twenty-seven patients with gastrointestinal tumors who underwent laparoscopic surgery at three tertiary A hospitals in Beijing were prospectively enrolled. Subsequently, logistic regression analysis was conducted to determine the independent predictors of early postoperative ambulation. Logistic regression analyses for the different gender were also performed. In addition, the effectiveness of preoperative grip strength measurement in nutritional risk assessment was analyzed by using nutritional risk score 2002 (NRS 2002) as a control. RESULTS The included cases were comprised of 283 male and 144 female patients, with an age of 59.35 ± 11.70 years. Gender, preoperative grip strength, operative time, and number of indwelling tubes were independent predictors of early postoperative ambulation. In the male group, lower preoperative grip strength and more indwelling tubes were independent risk factors for early postoperative ambulation. In the female group, lower preoperative grip strength and extended operating time were independent risk factors. Moreover, preoperative grip strength (male < 32 kg, female < 21 kg) can be used as a risk predictor for both preoperative nutritional risk and early postoperative ambulation. CONCLUSIONS As a simple and objective measure of muscle strength, grip strength measurement is expected to be an effective predictor for both early postoperative ambulation ability and nutritional status of patients.
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Affiliation(s)
- Jing Zhou
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiao Liu
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin Guo
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiuxiu Yang
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaonan Ma
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Weinan Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Wu EB, Li YY, Hung KC, Illias AM, Tsai YF, Yang YL, Chin JC, Wu SC. The Impact of Rocuronium and Sugammadex on Length of Stay in Patients Undergoing Open Spine Surgery: A Propensity Score-Matched Analysis. Bioengineering (Basel) 2023; 10:959. [PMID: 37627844 PMCID: PMC10451676 DOI: 10.3390/bioengineering10080959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Enhanced Recovery After Surgery (ERAS), an all-encompassing perioperative care approach, has been demonstrated to enhance surgical results, mitigate postoperative issues, and decrease the length of hospital stay (LOS) in diverse surgical specialties. In this retrospective study, our objective was to examine the influence of muscle relaxant selection on LOS and perioperative results in adult patients undergoing open spine surgery. Specifically, we compared 201 patients who received cisatracurium and neostigmine with 201 patients who received rocuronium and sugammadex, after 1:1 propensity score matching. The utilization of the rocuronium and sugammadex combination in anesthesia for open spinal surgery did not lead to a reduction in the LOS but was associated with a decreased incidence of postoperative chest radiographic abnormalities, including infiltration, consolidation, atelectasis, or pneumonia (p = 0.027). In our secondary analysis, multivariate analysis revealed multiple determinants influencing the prolonged LOS (>7 days) during open spine surgery. Bispectral index-guided anesthesia emerged as a protective factor, while variables such as excessive intraoperative blood loss and fluid administration as well as postoperative chest radiographic abnormalities independently contributed to prolonged LOS.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Yan-Yi Li
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan;
| | - Amina M. Illias
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (A.M.I.); (Y.-F.T.)
| | - Yung-Fong Tsai
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (A.M.I.); (Y.-F.T.)
| | - Ya-Ling Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung 813, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan;
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Rahman RK, Ginalis EE, Patel Y, San A, Kotrike S, Gajjar AA, Ghani H, Rahman MM. Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review. Neurochirurgie 2023; 69:101442. [PMID: 37062467 DOI: 10.1016/j.neuchi.2023.101442] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/30/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Postoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application. METHODS A literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL). RESULTS Twelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n=8). Non-opioid analgesia in ERAS improved postoperative pain control (n=4) and decreased the duration of pain (n=1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL. CONCLUSION Implementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.
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Affiliation(s)
- Raphia K Rahman
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA.
| | - Elizabeth E Ginalis
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yash Patel
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ali San
- Kansas City University College of Osteopathic Medicine, Kansas City, MO, USA
| | | | - Avi A Gajjar
- Department of Chemistry, Union College, Schenectady, NY, USA
| | - Hira Ghani
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY, USA
| | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
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Pintault C, Pondaven A, Lebechec A, Jugan AL, Coudriou C, Berti MDE, Ouldamer L. Implementation of Enhanced Recovery After Surgery Pathway for Patients Undergoing Mastectomy. J Gynecol Obstet Hum Reprod 2023; 52:102600. [PMID: 37150481 DOI: 10.1016/j.jogoh.2023.102600] [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: 01/01/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND - Mastectomy is still a common treatment for breast cancer. The introduction of the Enhanced Recovery After Surgery pathway (ERAS) having proven its benefits for major surgeries has not yet been validated for mastectomy without reconstruction. Our study was conducted to investigate the effects of implementing an ERAS pathway for mastectomies, including the length of hospital stay, postoperative complications and patient satisfaction. METHOD -The study population included all patients who underwent mastectomy without immediate breast reconstruction in the gynecological surgery department of the Tours University Hospital during the year 2020. We compared patients who underwent an ERAS protocol with those who were managed in a standard manner. RESULTS - Of the 92 patients managed for mastectomy, 32 were managed in the ERAS group. The two groups were comparable. We found fewer postoperative complications with this protocol in multivariate analysis. We also obtained a 37% response rate to the satisfaction questionnaires. We did not find any significant difference between the 2 groups. CONCLUSION - There is a trend towards a decrease in the length of hospitalization associated with a decrease in postoperative complications thanks to the implementation of a ERAS protocol for the management of mastectomies. Future studies should focus on both objective clinical outcomes and patient-reported experiences to provide a comprehensive understanding of the effectiveness of ERAS protocols in mastectomy patients.
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Affiliation(s)
- C Pintault
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - A Pondaven
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - A Lebechec
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - A L Jugan
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - C Coudriou
- Department of Anesthesiology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - M DE Berti
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - L Ouldamer
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France; INSERM unit 1069, Tours, France.
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Abstract
The human microbiome is vast and is present in spaces previously thought to be sterile such as the lungs. A healthy microbiome is diverse and functions in an adaptive way to support local as well as organism health and function. Furthermore, a normal microbiome is essential for normal immune system development rendering the array of microbes that live in and on the human body key components of homeostasis. A wide array of clinical conditions and interventions including anesthesia, analgesia, and surgical intervention may derange the human microbiome in a maladaptive fashion with bacterial responses spanning decreased diversity to transformation to a pathogenic phenotype. Herein, we explore the normal microbiome of the skin, gastrointestinal tract, and the lungs as prototype sites to describe the influence of the microbiomes in each of those locations on health, and how care may derange those relations.
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Yuan W, Huang G, Dai P, Zhong Y, Ai Q, Liao Q. Application of enhanced recovery after surgery in perioperative patients undergoing laparoscopic surgery for gastric cancer: A meta-analysis. Medicine (Baltimore) 2023; 102:e32962. [PMID: 36930125 PMCID: PMC10019270 DOI: 10.1097/md.0000000000032962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/24/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND To analyze the effect of enhanced recovery after surgery (ERAS) in perioperative patients undergoing laparoscopic surgery for gastric cancer (GC). METHODS We searched the literature databases of PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://www.webofscience.com/) for studies related to ERAS and laparoscopic surgery for GC from their inception till October 2022, and the retrieved articles were further screened for analysis. The literature quality was evaluated based on the Cochrane risk of bias tool. The endpoints included the first postoperative exhaust time, first postoperative bowel movement, length of stay, complications and hospitalization expenses. The meta-analysis was performed using RevMan 5.4 software. RESULTS 11 studies were included, involving 2039 patients. Meta-analysis showed that the first postoperative exhaust and bowel movement were earlier and the length of stay was shorter in the experimental group (e.g.,) than in the control group (CG) (P < .05). Moreover, a lower incidence of complications and markedly reduced hospitalization expenses were determined in for example (P < .05). Due to the heterogeneity in the comparison of indicators such as the first postoperative exhaust and bowel movement across articles, a funnel plot was drawn for observations. The plot was found to be basically symmetrical, indicating small results bias and reliable reference significance of our findings. CONCLUSION ERAS for perioperative patients undergoing laparoscopic surgery for GC can effectively shorten the postoperative rehabilitation cycle of patients, improve surgical safety and reduce treatment costs.
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Affiliation(s)
- Wei Yuan
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Guigui Huang
- Department of Infection, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Peng Dai
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - You Zhong
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Qiubao Ai
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Qinghui Liao
- Department of Nursing, Maternity and Child Health Hospital of Xinyu, Xinyu, Jiangxi Province, China
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25
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Lorenzon L, Caccialanza R, Casalone V, Santoro G, Delrio P, Izzo F, Tonello M, Mele MC, Pozzo C, Pedrazzoli P, Pietrabissa A, Fenu P, Mellano A, Fenocchio E, Avallone A, Bergamo F, Nardi MT, Persiani R, Biondi A, Tirelli F, Agnes A, Ferraris R, Quarà V, Milanesio M, Ribero D, Rinaldi M, D'Elia P, Rho M, Cenzi C, D'Ugo D. The impact of preoperative nutritional screening, ERAS protocol, and mini-invasive surgery in surgical oncology: A multi-institutional SEM analysis of patients with digestive cancer. Front Nutr 2023; 10:1041153. [PMID: 37006925 PMCID: PMC10063158 DOI: 10.3389/fnut.2023.1041153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundMini-invasive surgery (MIS), ERAS, and preoperative nutritional screening are currently used to reduce complications and the length of hospital stay (LOS); however, inter-variable correlations have seldom been explored. This research aimed to define inter-variable correlations in a large series of patients with gastrointestinal cancer and their impact on outcomes.MethodsPatients with consecutive cancer who underwent radical gastrointestinal surgery between 2019 and 2020 were analyzed. Age, BMI, comorbidities, ERAS, nutritional screening, and MIS were evaluated to determine their impact on 30-day complications and LOS. Inter-variable correlations were measured, and a latent variable was computed to define the patients' performance status using nutritional screening and comorbidity. Analyses were conducted using structural equation modeling (SEM).ResultsOf the 1,968 eligible patients, 1,648 were analyzed. Univariable analyses documented the benefit of nutritional screening for LOS and MIS and ERAS (≥7 items) for LOS and complications; conversely, being male and comorbidities correlated with complications, while increased age and BMI correlated with worse outcomes. SEM analysis revealed that (a) the latent variable is explained by the use of nutritional screening (p0·004); (b) the variables were correlated (age–comorbidity, ERAS–MIS, and ERAS–nutritional screening, p < 0·001); and (c) their impact on the outcomes was based on direct effects (complications: sex, p0·001), indirect effects (LOS: MIS-ERAS-nutritional screening, p < 0·001; complications: MIS-ERAS, p0·001), and regression-based effects (LOS: ERAS, MIS, p < 0·001, nutritional screening, p0·021; complications: ERAS, MIS, p < 0·001, sex, p0·001). Finally, LOS and complications were correlated (p < 0·001).ConclusionEnhanced recovery after surgery (ERAS), MIS, and nutritional screening are beneficial in surgical oncology; however, the inter-variable correlation is reliable, underlying the importance of the multidisciplinary approach.
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Affiliation(s)
- Laura Lorenzon
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
- *Correspondence: Laura Lorenzon
| | | | | | - Gloria Santoro
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Paolo Delrio
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Francesco Izzo
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Marco Tonello
- Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Maria Cristina Mele
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Carmelo Pozzo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | | | - Piero Fenu
- Candiolo Cancer Institute–IRCCS, Turin, Italy
| | | | | | - Antonio Avallone
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | | | | | - Roberto Persiani
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alberto Biondi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Flavio Tirelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Annamaria Agnes
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | | | | | | | | | | | - Maurizio Rho
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Carola Cenzi
- Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Domenico D'Ugo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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The Latest DISH: Thinking About Direct Discharge Home and Our Reception of the New and Good. Crit Care Med 2023; 51:156-158. [PMID: 36519994 DOI: 10.1097/ccm.0000000000005735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Johnson JE, Bleicher J, Blumling AN, Cain BT, Cohan JN, Savarise M, Harris AHS, Kaphingst KA, Huang LC. The Influence of Rural Healthcare Systems and Communities on Surgery and Recovery: A Qualitative Study. J Surg Res 2023; 281:155-163. [PMID: 36155272 PMCID: PMC10473841 DOI: 10.1016/j.jss.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/27/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Successful recovery after surgery is complex and highly individual. Rural patients encounter greater barriers to successful surgical recovery than urban patients due to varying healthcare and community factors. Although studies have previously examined the recovery process, rural patients' experiences with recovery have not been well-studied. The rural socioecological context can provide insights into potential barriers or facilitators to rural patient recovery after surgery. METHODS We conducted semi-structured qualitative interviews with a purposeful sample of 30 adult general surgery patients from rural areas in the Mountain West region of the United States. We used the socioecological framework to analyze their responses. Interviews focused on rural participants' experiences accessing healthcare and the impact of family and community support during postoperative recovery. Interviews were transcribed verbatim and coded using content and thematic analysis. RESULTS All participants commented on the quality of their rural healthcare systems and its influence on postoperative care. Some enjoyed the trust developed through long-standing relationships with providers in their communities. However, participants described community providers' lack of money, equipment, and/or knowledge as barriers to care. Following surgery, participants recognized that there are advantages and disadvantages to receiving family and community support. Some participants worried about being stigmatized or judged by their community. CONCLUSIONS Future interventions aimed at improving access to and recovery from surgery for rural patients should take into account the unique perspectives of rural patients. Addressing the socioecological factors surrounding rural surgery patients, such as healthcare, family, and community resources, will be key to improving postoperative recovery.
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Affiliation(s)
- Jordan E Johnson
- Department of Surgery, University of Utah, Salt Lake City, Utah.
| | - Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | | | - Brian T Cain
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Jessica N Cohan
- Department of Surgery, University of Utah, Salt Lake City, Utah; Huntsman Cancer Institute, Salt Lake City, Utah
| | - Mark Savarise
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Alex H S Harris
- VA HSR&D Center for Innovation to Implementation, Palo Alto VA Health Care System, Washington, District of Columbia
| | - Kimberly A Kaphingst
- Department of Communication, University of Utah, Salt Lake City, Utah; Huntsman Cancer Institute, Salt Lake City, Utah
| | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah; Huntsman Cancer Institute, Salt Lake City, Utah
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Nogueira PLB, Dock-Nascimento DB, de Aguilar-Nascimento JE. Extending the benefit of nutrition intervention beyond the operative setting. Curr Opin Clin Nutr Metab Care 2022; 25:388-392. [PMID: 36201609 DOI: 10.1097/mco.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update of the recent evidence on the potential of perioperative nutritional interventions to benefit adult patients undergoing head and neck and digestive procedures. RECENT FINDINGS Perioperative nutrition within multimodal prehabilitation programs improve postoperative outcomes. Perioperative fasting time can be reduced with beverages containing carbohydrate alone or blended with a nitrogenous source such as whey protein; this approach seems to be safe and improve outcome. The choice of protein-containing formula, as well as diet composition to be recommended early during the postoperative refeeding, can be optimized to reduce complications. Sarcopenia is an important risk factor for surgical patients, as such, prehabilitation along with preoperative nutrition is strongly advised. Perioperative supplementation with β-hydroxy β-methylbutyrate to mitigate sarcopenia requires further investigation. Although perioperative nutritional interventions reduce healthcare costs, recent data suggest it has been scarcely prescribed. SUMMARY Nutritional intervention is key in multimodal programs of enhanced recovery after surgery to ensure better outcomes. Perioperative fasting should be shortened, and include clear fluids containing carbohydrates and protein, especially in the early postoperative period. Multimodal prehabilitation is key to mitigate sarcopenia. Action to improve knowledge on the cost-effectiveness of nutritional interventions in the perioperative setting are needed.
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Affiliation(s)
- Paulo L Batista Nogueira
- UNIVAG Medical School, Varzea Grande
- Health Sciences Postgraduate Department, Medical School, Federal University of Mato Grosso, Cuiabá, Brazil
| | - Diana B Dock-Nascimento
- Health Sciences Postgraduate Department, Medical School, Federal University of Mato Grosso, Cuiabá, Brazil
| | - José E de Aguilar-Nascimento
- UNIVAG Medical School, Varzea Grande
- Health Sciences Postgraduate Department, Medical School, Federal University of Mato Grosso, Cuiabá, Brazil
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Lyu HG, Raut CP. What enhanced recovery means for patients with cancer undergoing surgery. Cancer 2022; 128:4058-4060. [PMID: 36219468 DOI: 10.1002/cncr.34480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Heather G Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Jian C, Zhou Z, Guan S, Fang J, Chen J, Zhao N, Bao H, Li X, Cheng X, Zhu W, Yang C, Shu X. Can an incomplete ERAS protocol reduce postoperative complications compared with conventional care in laparoscopic radical resection of colorectal cancer? A multicenter observational cohort and propensity score-matched analysis. Front Surg 2022; 9:986010. [PMID: 36090330 PMCID: PMC9458933 DOI: 10.3389/fsurg.2022.986010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The patients undergoing laparoscopic radical colorectomy in many Chinese hospitals do not achieve high compliance with the ERAS (enhanced recovery programs after surgery) protocol. Methods The clinical data from 1,258 patients were collected and divided into the non-ERAS and incomplete ERAS groups. Results A total of 1,169 patients were screened for inclusion. After propensity score-matched analysis (PSM), 464 pairs of well-matched patients were generated for comparative study. Incomplete ERAS reduced the incidence of postoperative complications (p = 0.002), both mild (6.7% vs. 10.8%, p = 0.008) and severe (3.2% vs. 6.0%, p = 0.008). Statistically, incomplete ERAS reduced indirect surgical complications (27,5.8% vs. 59, 12.7) but not local complications (19,4.1% vs. 19, 4.1%). The subgroup analysis of postoperative complications revealed that all patients benefited from the incomplete ERAS protocol regardless of sex (male, p = 0.037, 11.9% vs. 17.9%; female, p = 0.010, 5.9% vs. 14.8%) or whether neoadjuvant chemotherapy was administered (neoadjuvant chemotherapy, p = 0.015, 7.4% vs. 24.5%; no neoadjuvant chemotherapy, p = 0.018, 10.2% vs. 15.8%). Younger patients (<60 year, p = 0.002, 7.6% vs. 17.5%) with a low BMI (<22.84, 9.4% vs. 21.1%, p < 0.001), smaller tumor size (<4.0 cm, 8.1% vs. 18.1%, p = 0.004), no fundamental diseases (8.8% vs. 17.0%, p = 0.007), a low ASA score (1/2, 9.7% vs. 16.3%, p = 0.004), proximal colon tumors (ascending/transverse colon, 12.2% vs. 24.3%, p = 0.027), poor (6.1% vs. 23.7%, p = 0.012)/moderate (10.3% vs. 15.3%, p = 0.034) tumor differentiation and no preoperative neoadjuvant radiotherapy (10.3% vs. 16.9%, p = 0.004) received more benefit from the incomplete ERAS protocol. Conclusion The incomplete ERAS protocol decreased the incidence of postoperative complications, especially among younger patients (<60 year) with a low BMI (<22.84), smaller tumor size (<4.0 cm), no fundamental diseases, low ASA score (1/2), proximal colon tumors (ascending/transverse colon), poor/moderate differentiation and no preoperative neoadjuvant radiotherapy. ERAS should be recommended to as many patients as possible, although some will not exhibit high compliance. In the future, the core elements of ERAS need to be identified to improve the protocol.
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Affiliation(s)
- Chenxing Jian
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Zili Zhou
- Department of Gastrointestinal Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shen Guan
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jianying Fang
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Jinhuang Chen
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Zhao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haijun Bao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xianguo Li
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xukai Cheng
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhong Zhu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunkang Yang
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Xiaogang Shu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lee B, Han HS. Tackling Surgical Morbidity and Mortality through Modifiable Risk Factors in Cancer Patients. Nutrients 2022; 14:nu14153107. [PMID: 35956284 PMCID: PMC9370480 DOI: 10.3390/nu14153107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Despite advances in surgical techniques, surgical morbidity and mortality remain important public health problems. Postoperative complications often lead to greater morbidity and mortality, as well as increased length of hospital stay and medical costs. Therefore, a reduction in postoperative complications is particularly important with regard to positive long-term outcomes in patients with cancer. To improve patients’ postoperative prognosis, it is necessary to screen for and focus on modifiable risk factors and their subsequent resolution. Recently, it was reported that nutritional status, inflammation and surgical approaches are related to postoperative morbidity and mortality. Therefore, in this review article, we describe the current evidence regarding modifiable risk factors influencing surgical morbidity and mortality as well as future directions for improved postoperative management in cancer patients.
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Principles of enhanced recovery in gastrointestinal surgery. Langenbecks Arch Surg 2022; 407:2619-2627. [PMID: 35861873 DOI: 10.1007/s00423-022-02602-9] [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: 05/24/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To reduce the impact of surgery-related stress, enhanced recovery after surgery (ERAS) pathways have been developed since over 15 years with subsequent improved postoperative outcome. This multimodal and evidence-based perioperative approach has spread to all fields of gastrointestinal surgery, from esophagus, stomach, duodenum and pancreas, liver, small intestine and colon, and rectum, as well as for other specialties like vascular and cardia surgeries or neurosurgery, among others. PURPOSE The aim of this state-of-the-art article is to assess current state of evidence on perioperative management specifically in gastrointestinal surgery, with a focus on surgery-related aspects, outcome benefit, and future directions. CONCLUSION The surgical team must promote continuous improvement of the patient's ERAS compliance to ensure optimal perioperative care. Everyday clinical practice should be performed according to latest evidence-based medicine and challenging surgical dogma. Moreover, the surgeon must lead and support a multidisciplinary and collaborative teamwork tailored to patient's need especially with anesthetists and nursing staff.
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Zhang W, Zhang Y, Qin Y, Shi J. Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022; 9:100110. [PMID: 36158708 PMCID: PMC9500517 DOI: 10.1016/j.apjon.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/13/2022] [Indexed: 11/02/2022] Open
Abstract
Objective Methods Results Conclusions
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Schaaf S, Willms A, Schwab R, Güsgen C. Recommendations on postoperative strain and physical labor after abdominal and hernia surgery: an expert survey of attendants of the 41st EHS Annual International Congress of the European Hernia Society. Hernia 2022; 26:727-734. [PMID: 33629178 PMCID: PMC9200870 DOI: 10.1007/s10029-021-02377-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are no valid recommendations or reliable guidelines available to guide patients how long they should refrain from lifting weights or returning to heavy physical labor after abdominal or hernia surgery. Recent studies found that surgeons' recommendations not to be evidence-based and might be too restrictive considering data on fascial healing and incisional hernia development. It is likely that this impairs the patient's quality of life and leads to remarkable socio-economic costs. Hence, we conducted this survey to gather international expert's opinions on this topic. MATERIALS AND METHODS At the 41st Annual International Congress of the EHS, attending international experts were asked to complete a questionnaire concerning recommendations on given proposals for postoperative refrain from heavy work or lifting after abdominal surgery and also after hernia repairs. RESULTS In total, 127 experts took part in the survey. 83.9% were consultants with a mean experience since specialization of more than 11 years. Two weeks of no heavy physical strain after laparoscopic surgery were considered sufficient by more than 50% of the participants. For laparotomy, more than 50% rated 4 weeks appropriate. For mesh-augmented sublay and IPOM repair of ventral or incisional hernias, more than 50% rated 4 weeks of rest appropriate. For complex hernia repair, 37% rated 4 weeks reasonable. Two weeks after, groin hernia surgery was considered sufficient by more than 50% of the participants. CONCLUSION Following groin hernia repair (Lichtenstein/endoscopic technique) and laparoscopic operation, the majority agreed on the proposal of 2 weeks refraining from physical strain. Four weeks of no physical strain were considered appropriate by a majority after laparotomy and open incisional hernia repair. However, the results showed substantial variation in the ratings, which indicates uncertainty even in this selected cohort of hernia surgery experts and emphasizes the need for further scientific evaluation. This is particularly remarkable, because a lack of evidence that early postoperative strain leads to higher incisional hernia rates. TRIAL REGISTRATION Number DRKS00023887.
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Affiliation(s)
- S Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
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Jin L, Miao Y, Liu D, Song F. Fe/Mn‐Porphyrin Coordination Polymer Nanoparticles for Magnetic Resonance Imaging (MRI) Guided‐Combination Therapy between Photodynamic Therapy and Chemodynamic Therapy. ChemistrySelect 2022. [DOI: 10.1002/slct.202104366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lin Jin
- Institute of Molecular Sciences and Engineering Institute of Frontier and Interdisciplinary Science Shandong University Qingdao Shandong 266237 China
| | - Yuyang Miao
- Institute of Molecular Sciences and Engineering Institute of Frontier and Interdisciplinary Science Shandong University Qingdao Shandong 266237 China
| | - Dapeng Liu
- Institute of Molecular Sciences and Engineering Institute of Frontier and Interdisciplinary Science Shandong University Qingdao Shandong 266237 China
| | - Fengling Song
- Institute of Molecular Sciences and Engineering Institute of Frontier and Interdisciplinary Science Shandong University Qingdao Shandong 266237 China
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El-Boghdadly K, Jack JM, Heaney A, Black ND, Englesakis MF, Kehlet H, Chan VWS. Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials. Reg Anesth Pain Med 2022; 47:282-292. [PMID: 35264431 DOI: 10.1136/rapm-2021-103256] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/25/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear. OBJECTIVE We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS. EVIDENCE REVIEW We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. FINDINGS Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques. CONCLUSIONS Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice. PROSPERO REGISTRATION NUMBER CRD42020161200.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - James M Jack
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aine Heaney
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nick D Black
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Marina F Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Vincent W S Chan
- Department of Anesthesiology and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Chorath K, Hobday S, Suresh NV, Go B, Moreira A, Rajasekaran K. Enhanced recovery after surgery protocols for outpatient operations in otolaryngology: Review of literature. World J Otorhinolaryngol Head Neck Surg 2022; 8:96-106. [PMID: 35782396 PMCID: PMC9242417 DOI: 10.1002/wjo2.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/07/2021] [Indexed: 11/12/2022] Open
Abstract
Objective Enhanced recovery after surgery (ERAS) protocols are patient‐centered, evidence‐based pathways designed to reduce complications, promote recovery, and improve outcomes following surgery. These protocols have been successfully applied for the management of head and neck cancer, but relatively few studies have investigated the applicability of these pathways for other outpatient procedures in otolaryngology. Our goal was to perform a systematic review of available evidence reporting the utility of ERAS protocols for the management of patients undergoing outpatient otolaryngology operations. Methods A systematic literature review was conducted using MEDLINE, EMBASE, SCOPUS, and gray literature. We identified studies that evaluated ERAS protocols among patients undergoing otologic, laryngeal, nasal/sinus, pediatric, and general otolaryngology operations. We assessed the outcomes and ERAS components across protocols as well as the study design and limitations. Results A total of eight studies fulfilled the inclusion criteria and were included in the analysis. Types of procedures evaluated with ERAS protocols included tonsillectomy and adenoidectomy, functional endoscopic sinus surgery, tympanoplasty and mastoidectomy, and septoplasty. A reduction in postoperative length of stay and hospital costs was reported in two and three studies, respectively. Comparative studies between ERAS and control groups showed persistent improvement in pre‐ and postoperative anxiety and pain levels, without an increase in postoperative complications and readmission rates. Conclusions A limited number of studies discuss implementation of ERAS protocols for outpatient operations in otolaryngology. These clinical pathways appear promising for these procedures as they may reduce length of stay, decrease costs, and improve pain and anxiety postoperatively. Enhanced recovery after surgery (ERAS) protocols in outpatient otolaryngology operations are effective in significantly decreasing hospital length of stay, hospital costs, and postoperative pain/anxiety. The most common components among ERAS protocols were postoperative analgesia regimen, postoperative nutrition, fluid management, and preoperative education/counseling.
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Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Sara Hobday
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Neeraj V. Suresh
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Beatrice Go
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Alvaro Moreira
- Department of Pediatrics University of Texas Health‐San Antonio San Antonio Texas USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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Chiewhatpong P, Charoenkwan K, Smithiseth K, Lapisatepun W, Lapisatepun P, Phimphilai M, Muangmool T, Cheewakriangkrai C, Suprasert P, Srisomboon J. Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial. Int J Gynaecol Obstet 2022; 159:568-576. [PMID: 35396709 DOI: 10.1002/ijgo.14211] [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: 11/11/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy. METHODS From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre-specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain. RESULTS The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained. CONCLUSION The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population. CLINICAL TRIAL REGISTRATION The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3.
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Affiliation(s)
- Phasawee Chiewhatpong
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipat Charoenkwan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kannika Smithiseth
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Panuwat Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tanarat Muangmool
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chalong Cheewakriangkrai
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prapaporn Suprasert
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jatupol Srisomboon
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Band IC, Yenicay AO, Montemurno TD, Chan JS, Ogden AT. Enhanced Recovery After Surgery Protocol in Minimally Invasive Lumbar Fusion Surgery Reduces Length of Hospital Stay and Inpatient Narcotic Use. World Neurosurg X 2022; 14:100120. [PMID: 35257094 PMCID: PMC8897578 DOI: 10.1016/j.wnsx.2022.100120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background The application of enhanced recovery after surgery (ERAS) has the potential to improve outcomes, hasten patient recovery, and reduce costs. ERAS has been applied to spine surgery for several years, but data are limited around the impact of ERAS on minimally invasive spine surgery, specifically. The authors report their experience implementing a multimodal ERAS protocol for patients receiving minimally invasive transforaminal lumbar interbody fusion. Methods The ERAS protocol was implemented at The Valley Hospital Hospital in Ridgewood, New Jersey in January 2020. Following implementation, all patients receiving minimally invasive transforaminal lumbar interbody fusion by a single surgeon were studied. The authors analyze the impact of the protocol on length of stay (LOS), disposition post discharge, and opioid consumption postoperatively in the inpatient and outpatient settings. Results Sixteen patients were enrolled in the protocol and compared with 17 historical controls. LOS was significantly shorter in the ERAS cohort (1.6 vs. 2.4 days, P = 0.022). There was no significant difference between the groups with respect to disposition; the majority of patients were discharged to home without need for in-home medical services. Patients in the ERAS cohort consumed significantly fewer opioid analgesics postoperatively in the inpatient setting (51 mg morphine milligram equivalents vs. 320 mg morphine milligram equivalents, P = 0.00016). On average, patients in the ERAS cohort were prescribed fewer opioids analgesics post discharge. Conclusions ERAS application to minimally invasive transforaminal lumbar interbody fusion was safe and effective, significantly reducing LOS and inpatient opioid consumption. These data reflect the importance of uniformly applying a multimodal ERAS protocol to accelerate recovery and reduce narcotic use.
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Affiliation(s)
- Isabelle C Band
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, United States
| | - Altan O Yenicay
- Department of Anesthesiology, The Valley Hospital, Ridgewood, New Jersey, United States
| | - Tina D Montemurno
- Department of Anesthesiology, The Valley Hospital, Ridgewood, New Jersey, United States
| | - Jenny S Chan
- Department of Anesthesiology, The Valley Hospital, Ridgewood, New Jersey, United States
| | - Alfred T Ogden
- Department of Neurosurgery, The Valley Hospital, Ridgewood, New Jersey, United States.,Department of Neurosurgery, NYU Langone Hospitals, New York, New York, United States
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Vermişli S, Çakmak Ö, Müezzinoğlu T, Aslan G, Baydur H. The Effect of Postoperative Early Mobilization on the Healing Process and Quality of Life Following Radical Cystectomy and Ileal Conduit: A Randomized Prospective Controlled Trial. JOURNAL OF UROLOGICAL SURGERY 2022. [DOI: 10.4274/jus.galenos.2021.2021.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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Guerra A, Chao C, Wallace GA, Rodriguez HE, Eskandari MK. Changes in Anesthesia Can Reduce Periprocedural Urinary Retention After EVAR. Ann Vasc Surg 2022; 79:91-99. [PMID: 34687889 PMCID: PMC8821118 DOI: 10.1016/j.avsg.2021.08.033] [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: 06/02/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs provide a streamlined approach for expedient postoperative care of high-volume procedures. Endovascular aortic repair (EVAR) has become standard treatment for abdominal aortic aneurysms and implementation of an early recovery program is warranted. Postoperative urinary retention (POUR) remains a problem lending to longer hospital stays and patient discomfort. We aim to demonstrate the utility of monitored anesthetic care (MAC) plus local anesthesia as a modality to minimize urinary retention following EVAR. METHODS Single-center retrospective review from January 2017 to March 2020 of all patients undergoing standard elective EVAR under general anesthesia or MAC anesthesia. Local anesthetic at vessel access sites was used in all patients under MAC. Ruptured pathology and female sex were excluded from analysis. Patient characteristics, operative details, prostate measurements, and outcomes were abstracted from the electronic medical record. Urinary retention was defined as any requirement of straight catheterization, urinary catheter replacement, or discharge with urinary catheter. Chi square tests and logistic regression were used to determine predictors associated with POUR and increased hospital length of stay. RESULTS Among 138 patients who underwent EVAR, eight (5.8%) were excluded due to ruptured pathology. Of the cohort, 113 (86.9%) were male with mean age of 73 years. Excluding female patients, 63 (55.8%) male patients underwent general anesthesia and 50 (44.3%) underwent MAC. Male patients under general anesthesia were more likely to have intra-operative urinary catheter placement when compared to MAC (82.5% vs. 36%, respectively; P < 0.001). POUR was identified in 17 patients (13.1%) of the entire study population with 15 events (88.2%) occurring in males. Excluding patients who were admitted to the ICU, twenty-two (19.5%) male patients stayed past postoperative day (POD) one, of which those who developed POUR were more likely to experience compared to those without POUR (45.6% vs. 9.7%, respectively; P = 0.001). On multivariable analysis, male patients who received MAC had a lower risk of developing POUR (OR 0.09, 95% CI 0.02-0.50). POUR was not associated with elective urinary catheter placement nor with pre-existing conditions such as diabetes, urinary retention, benign prostatic hypertrophy (BPH), or use of BPH medications. Additionally, neither prostate size nor volume was associated with developing POUR among male patients. CONCLUSION MAC plus local anesthesia is associated with decreased rates of POUR after elective EVAR in male patients. ERAS pathways during elective EVAR interventions should implement MAC plus local anesthesia as an acceptable anesthetic option, where appropriate, in order to reduce urinary retention rates and subsequently decrease hospital length of stay in this patient cohort.
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Affiliation(s)
- Andres Guerra
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611,Corresponding Author: Andres Guerra, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611,
| | - Calvin Chao
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611
| | - Gabriel A Wallace
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611
| | - Heron E Rodriguez
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611
| | - Mark K Eskandari
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, 676 N St. Clair Street, Suite 650, Chicago, Illinois 60611
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Perceptions of Experiences of Recovery After Pancreaticoduodenectomy—A Phenomenographic Interview Study. Cancer Nurs 2022; 45:172-180. [DOI: 10.1097/ncc.0000000000001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth 2022; 128:434-448. [PMID: 35012741 DOI: 10.1016/j.bja.2021.12.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/03/2021] [Accepted: 12/05/2021] [Indexed: 12/12/2022] Open
Abstract
This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
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Srinivasaraghavan N, Das N, Balakrishnan K, Rajaram S. Effect of Whey Protein Supplementation on Perioperative Outcomes in Patients with Cancer-A Systematic Review and Meta-Analysis (PROSPERO 2020: CRD42020188666). Nutr Cancer 2021; 74:2351-2364. [PMID: 34961401 DOI: 10.1080/01635581.2021.2020302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Whey protein has several biochemical characteristics which make it an ideal nutritional supplement in cancer. This meta-analysis aims to evaluate the effects of whey on perioperative outcomes in cancer. A systematic review was conducted as per the Preferred Reporting of Systematic Reviews and Meta-analysis (PRISMA) guidelines. The primary outcome was postoperative complications. Secondary outcomes included 6-minute walk test, length of stay (LOS), and thirty-day readmission. Of the ten trials, six supplemented whey to meet protein requirements of around 1.2 mg/kg/day, and four supplemented whey variably. A synthesis of ten trials with 643 patients showed significantly decreased postoperative complications in the whey supplemented (22%) group as compared to the control (32%) (OR 0.61, 95% CI 0.41-0.90; P = 0.01). Analysis of six trials showed that patients supplemented with whey had greater functional walking capacity before surgery (MD 23.76 meters, 95% CI 4.05-43.47; participants = 377; P = 0.02) and after 4 weeks of surgery (MD 45.76, 95% CI 14.19-77.33; participants = 366; P = 0.004). Thirty-day readmissions and LOS showed no differences. Risk of bias varied between the trials and evidence was moderate to low. Whey protein supplementation improved the perioperative functional capacity and significantly reduced postoperative complications in patients with cancer.
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Affiliation(s)
| | - Nairita Das
- Department of Anesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Kalpana Balakrishnan
- Department of Anesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Swaminathan Rajaram
- Department of Biostatistics and Cancer Registry, Cancer Institute (WIA), Chennai, Tamil Nadu, India
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Enhanced recovery after posterior deep infiltrating endometriosis surgery: a national study. Fertil Steril 2021; 117:376-383. [PMID: 34949453 DOI: 10.1016/j.fertnstert.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the impact of the implementation of a national enhanced recovery after surgery (ERAS) program for posterior deep infiltrating endometriosis (DIE) surgery on the length of hospital stay, the rate of postoperative complications, and readmission within 30 days. DESIGN Comparative exposed/nonexposed observational study. SETTING Study based on the French national medicoeconomic database of the Program of Medicalization of Information System. PATIENTS Seven hundred and sixty-four women who underwent DIE surgery were involved and matched (1:3 ratio) into two groups: ERAS group for the year 2019 and non-ERAS group for the year 2015. INTERVENTIONS Surgical management for posterior DIE. MAIN OUTCOME MEASURES The length of hospital stay, the rate of postoperative complications during the initial hospital stay, and readmission within 30 days. RESULTS The ERAS group included 191 women, and the non-ERAS group included 573 women. The mean length of hospital stay was shorter in the ERAS group than in the non-ERAS group (4.28 ± 3.80 days vs. 5.42 ± 4.04 days, respectively). The rate of postoperative abdominal or pelvic pain syndromes was lower in the ERAS group than in the non-ERAS group (5/191 (2.62%) vs. 48/573 (8.38%), respectively; relative risk, 0.31 [0.125-0.7969]). The rate of postoperative complication and the rate of readmission within 30 days were not different between the two groups. CONCLUSIONS The implementation of ERAS has a significant positive impact on patient outcomes after DIE surgery. The length of hospital stay and abdominal or pelvic pain syndromes were reduced without increasing complications or readmission within 30 days.
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Moris D, Lim JJ, Cerullo M, Schmitz R, Shah KN, Blazer DG, Lidsky ME, Allen PJ, Zani S. Empiric nasogastric decompression after pancreaticoduodenectomy is not necessary. HPB (Oxford) 2021; 23:1906-1913. [PMID: 34154924 DOI: 10.1016/j.hpb.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 04/16/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the impact of routine NGT decompression after PD on postoperative outcomes in the era of an enhanced recovery after surgery (ERAS) protocol. MATERIALS AND METHODS A retrospective review of all patients undergoing PD between January 2015 and October 2017 at our institution was performed comparing routine post-operative NGT decompression versus omission. The incidence of delayed gastric emptying, post-operative pancreatic fistula, hospital length of stay, operative time, 30-day readmission rate as well the time to first oral intake were evaluated. RESULTS Out of 149 patients who underwent PD, 65 maintained post-operative NGT decompression while post-operative NGT decompression was omitted in 84 patients. No differences were noted in delayed gastric emptying rates (both p>0.05). The median length of stay (9 days for NGT group versus 8.5 days for no NGT group) and 30-day readmission rates (13.8% versus 15.5%, respectively) were similar (p=0.781). Compared with patients who had routine post-operative NGT placed, those who had omission of a post-operative NGT had a lower need for reinsertion, shorter time to PO intake, and a lower likelihood of extended length of stay. CONCLUSIONS In the era of ERAS protocols, we observed no association between routine post-operative NGT decompression after PD and improved postoperative outcomes.
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Affiliation(s)
- Dimitrios Moris
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Jenny J Lim
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marcelo Cerullo
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Robin Schmitz
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N Shah
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael E Lidsky
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J Allen
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Xie QY, Yang J, Lei ZH, Gao FW, Chen B, Jiang KY, Xiong H, Yang J. Exploring the Application of a Multi-Targeted Nursing Group for Enhanced Recovery After Surgery Using the LEER ("Less Pain", "Early Movement", "Early Return to a Normal Diet" and "Reassurance") Model. Int J Gen Med 2021; 14:7187-7196. [PMID: 34737614 PMCID: PMC8558503 DOI: 10.2147/ijgm.s329837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To explore the effects and value of establishing a multi-target nursing group (MTNG) for facilitating goal-oriented enhanced recovery after surgery (ERAS) using the LEER ("less pain", "early movement", "early return to a normal diet" and "reassurance") model. Methods The clinical data of 198 patients with hepatobiliary and pancreatic malignancies were retrospectively analyzed. The patients were divided into two groups: 91 cases were collected in a traditional group, which adopted traditional perioperative care, and 107 cases were collected in an MTNG group, which adopted MTNG measures. The differences in the clinical data including postoperative recovery, unplanned readmission rate, the implementation rate of nursing measures, the degree of a patient's understanding of the disease, and patient compliance and satisfaction with nursing care during hospitalization were compared and analyzed between the two groups. Results The MTNG group reflected a lower pain degree and hospitalization expenses (P < 0.05), earlier postoperative flatulence, earlier recommencing of a normal diet, and earlier postoperative ambulation (P < 0.05), together with a shorter postoperative indwelling catheter duration and length of hospital stay (P < 0.05). There were no significant differences in the incidence of postoperative complications and unplanned postoperative readmission rates between the two groups (P > 0.05). The implementation rate of nursing measures and the degree of patients understanding the disease, and patient compliance and satisfaction with nursing care were higher in the MTNG group (P < 0.05). Conclusion The MTNG approach, based on ERAS with the LEER model, was conducive to the safe and rapid postoperative recovery of patients, the precise and efficient implementation of ERAS measures, the improvement of medical treatment satisfaction among patients.
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Affiliation(s)
- Qing-Yun Xie
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Jie Yang
- Diagnosis and Treatment Center of Hepatobiliary Pancreatic Splenic Systemic Disease in Leshan, The Second Batch of Hepatobiliary and Pancreatic ERAS Standard Wards of Hubei Chen Xiaoping Science and Technology Development Foundation, Leshan, Sichuan, 614000, People's Republic of China
| | - Ze-Hua Lei
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Feng-Wei Gao
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Bing Chen
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Kang-Yi Jiang
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Hui Xiong
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
| | - Jie Yang
- Department of Hepatobiliary Pancreatic Splenic Surgery, The People's Hospital of Leshan, Leshan, Sichuan, 614000, People's Republic of China
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Moons J, Depypere L, Lerut T, van Achterberg T, Coosemans W, Van Veer H, Mandeville Y, Nafteux P. Impact of the introduction of an enhanced recovery pathway in esophageal cancer surgery: a cohort study and propensity score matching analysis. Dis Esophagus 2021; 34:6141530. [PMID: 33598683 DOI: 10.1093/dote/doab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/10/2020] [Accepted: 12/24/2020] [Indexed: 12/11/2022]
Abstract
Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P<0.0001 and 17% vs. 12%; P<0.0001, respectively) and postoperative blood transfusion (26.7%-11%; P<0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10-23) in TC compared with 10 days (IQR 8-14) in ERP patients (P<0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P=0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P=0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P=0.0001), anastomotic leak (P=0.047), several infectious complications (P=0.01-0.034), blood transfusion (P=0.001), Comprehensive Complications Index (P=0.01), and length of stay (P=0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates.
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Affiliation(s)
- J Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - L Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - W Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Y Mandeville
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Schaaf S, Schwab R, Güsgen C, Vilz TO, Willms A. Recommendations on Postoperative Activities After Abdominal Operations and Incisional Hernia Repair-A National and International Survey. Front Surg 2021; 8:713138. [PMID: 34660675 PMCID: PMC8511488 DOI: 10.3389/fsurg.2021.713138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background: There is no conclusive data on postoperative recommendations after abdominal and hernia surgery, and there is significant variation in the literature on that question. Thus, this study evaluates the status quo of recommendations of postoperative activity restriction after abdominal surgery. Materials and Methods: A national (German) and international survey of general surgeons on postoperative recommendations after abdominal and hernia surgery was pooled and analyzed. Results: A total of 74.6% recommended postoperative reduced activity for 2 weeks or less after laparoscopy. For midline laparotomy, 48.8% considered a reduced activity of 4 weeks or less to be sufficient. A majority from the national survey recommended more than 4 weeks instead (60.2%), whereas only 31.5% from the international survey did so (p = 0.000). In the pooled analysis, 258 of 450 (57.3%) rated 4 weeks or less suitable. However, the recommendations differed significantly between the surveys (4 weeks or less: a national survey, 47.1% vs. international survey, 64.6%; p = 0.000). Conclusion: There was substantial variation in the given recommendations. However, we found no evidence against immediate mobilization, reduced physical activity, and lifting for up to 2 weeks after laparoscopic surgery and for up to 4 weeks after open abdominal surgery and open incisional/ventral hernia repair in uncomplicated and standard cases. There might be individual and socioeconomic benefits to allow patients to return to their whole personal level of activity and work without putting them at risk of complications. Due to lack of evidence, both retrospective and prospective, controlled studies are in need to develop reliable recommendations.
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Affiliation(s)
- Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Tim O. Vilz
- Department of General, Visceral, Thoracic and Vasular Surgery, University Hospital Bonn, Bonn, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
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