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Salenger R, Ad N, Grant MC, Bakaeen F, Balkhy HH, Mick SL, Sardari Nia P, Kempfert J, Bonaros N, Bapat V, Wyler von Ballmoos MC, Gerdisch M, Johnston DR, Engelman DT. Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS). INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241264565. [PMID: 39205530 DOI: 10.1177/15569845241264565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.
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Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Niv Ad
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael C Grant
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH, USA
| | - Husam H Balkhy
- Section of Cardiac Surgery, University of Chicago Medicine, IL, USA
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medicine, NY, USA
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre, The Netherlands
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Vinayak Bapat
- Department of Cardiothoracic Surgery, Abbott Northwestern Hospital Allina Health, Minneapolis, MN, USA
| | - Moritz C Wyler von Ballmoos
- Department of Cardiovascular and Thoracic Surgery, Texas Health Harris Methodist Hospital, Fort Worth, TX, USA
| | - Marc Gerdisch
- Department of Cardiothoracic Surgery, Franciscan Health Indianapolis, IN, USA
| | - Douglas R Johnston
- Division of Cardiac Surgery, Department of Surgery, Northwestern University School of Medicine, Chicago, IL, USA
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
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Wu Z, Ge X, Shi D. ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2024. [PMID: 39172651 DOI: 10.1089/sur.2024.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.
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Affiliation(s)
- Zhiwei Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Xiaofang Ge
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Dike Shi
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
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Cho E, Kwak JH, Huh J, Kang IS, Ryu KH, Lee SH, Ahn JH, Choi HK, Song J. A comparative study using gastric ultrasound to evaluate the safety of shortening the fasting time before pediatric echocardiography: a randomized controlled non-inferiority study. J Anesth 2024; 38:516-524. [PMID: 38849566 DOI: 10.1007/s00540-024-03360-2] [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: 12/04/2023] [Accepted: 05/09/2024] [Indexed: 06/09/2024]
Abstract
PURPOSE The objective of this study was to demonstrate that the gastric cross-sectional area (CSA) in the right lateral decubitus position (RLDP) during a 2-h fasting period is not larger than that during a conventional 4-h fasting period prior to pediatric echocardiography. METHODS 93 patients aged under 3 years scheduled for echocardiography under sedation were enrolled and randomly allocated into two groups; 2-h fasting vs 4-h fasting. For group 4 h (n = 46), the patients were asked to be fasted for all types of liquid for more than 4 h, while group 2 h (n = 47) were asked to be fasted for all types of liquid for 2 h before echocardiography. Gastric ultrasound was performed before echocardiography, and CSARLDP was measured. We compared CSARLDP, incidence of at-risk stomach, fasting duration, and the incidence of major (pulmonary aspiration, aspiration pneumonia) and minor complications (nausea, retching, and vomiting, apnea, and bradycardia) between two groups. RESULTS The mean difference of CSARLDP (group 2 h-group 4 h) was 0.49 (- 0.18 to 1.17) cm2, and it was within the non-inferiority margin (Δ = 2.1 cm2). There was no difference in the incidence of at-risk stomach (P = 0.514). There was no significant difference in the incidence of major and minor complications between the two groups. CONCLUSION Two-hour fasting in pediatric patients who need an echocardiography did not increase major and minor complications and CSA significantly.
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Affiliation(s)
- Eunah Cho
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Hee Kwak
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - I-Seok Kang
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Kyoung-Ho Ryu
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeong-Kyeong Choi
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea.
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Qin J, Gou LY, Zhang W, Pu X, Zhang P. Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2024; 34:710-720. [PMID: 38976496 DOI: 10.1089/lap.2024.0119] [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: 07/10/2024] Open
Abstract
Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.
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Affiliation(s)
- Jiao Qin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ling-Yan Gou
- Surgical Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wei Zhang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiao Pu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ping Zhang
- Anesthetic Surgery Sichuan Provincial People's Hospital, Nanchong, China
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Fonseca MK, Rizental LB, da Cunha CEB, Baldissera N, Wagner MB, Fraga GP. Applying enhanced recovery principles to emergency laparotomy in penetrating abdominal trauma: a case-matched study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02577-w. [PMID: 38940950 DOI: 10.1007/s00068-024-02577-w] [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: 05/15/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE The implementation of enhanced recovery after surgery programs (ERPs) has significantly improved outcomes within various surgical specialties. However, the suitability of ERPs in trauma surgery remains unclear. This study aimed to (1) design and implement an ERP for trauma laparotomy patients; (2) assess its safety, feasibility, and efficacy; and (3) compare the outcomes of the proposed ERP with conventional practices. METHODS This case-matched study prospectively enrolled hemodynamically stable patients undergoing emergency laparotomy after penetrating trauma. Patients receiving the proposed ERP were compared to historical controls who had received conventional treatment from two to eight years prior to protocol implementation. Cases were matched for age, sex, injury mechanism, extra-abdominal injuries, and trauma scores. Assessment of intervention effects were modelled using regression analysis for outcome measures, including length of hospital stay (LOS), postoperative complications, and functional recovery parameters. RESULTS Thirty-six consecutive patients were enrolled in the proposed ERP and matched to their 36 historical counterparts, totaling 72 participants. A statistically significant decrease in LOS, representing a 39% improvement in average LOS was observed. There was no difference in the incidence of postoperative complications. Opioid consumption was considerably lower in the ERP group (p < 0.010). Time to resumption of oral liquid and solid intake, as well as to the removal of nasogastric tubes, urinary catheters, and abdominal drains was significantly earlier among ERP patients (p < 0.001). CONCLUSION The implementation of a standardized ERP for the perioperative care of penetrating abdominal trauma patients yielded a significant reduction in LOS without increasing postoperative complications. These findings demonstrate that ERPs principles can be safely applied to selected trauma patients.
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Affiliation(s)
- Mariana Kumaira Fonseca
- Hospital de Pronto Socorro de Porto Alegre, Porto Alegre, Brazil.
- State University of Campinas, Campinas, Brazil.
| | | | - Carlos Eduardo Bastian da Cunha
- Hospital de Pronto Socorro de Porto Alegre, Porto Alegre, Brazil
- Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Neiva Baldissera
- Hospital de Pronto Socorro de Porto Alegre, Porto Alegre, Brazil
| | - Mário Bernardes Wagner
- Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Matos AN, Silvestre SCDM, Fernandes SL, Pereira AA, Pimentel RFW, Carvalho-Rassbach M, de Albuquerque LC, Iucif N. Nutrological therapy in oncology: from prevention to nutritional support during treatment. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e2024S123. [PMID: 38865543 PMCID: PMC11164267 DOI: 10.1590/1806-9282.2024s123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/31/2023] [Indexed: 06/14/2024]
Affiliation(s)
| | | | | | | | | | | | | | - Nelson Iucif
- Brazilian Association of Nutrology – Catanduva (SP), Brazil
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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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Parker SG, Joyner J, Thomas R, Van Dellen J, Mohamed S, Jakkalasaibaba R, Blake H, Shanmuganandan A, Albadry W, Panascia J, Gray W, Vig S. A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction. Am Surg 2024; 90:1714-1726. [PMID: 38584505 DOI: 10.1177/00031348241241650] [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: 04/09/2024]
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. METHODS We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. RESULTS We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. CONCLUSION In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.
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Affiliation(s)
- Samuel G Parker
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - James Joyner
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Rhys Thomas
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Jonathan Van Dellen
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Said Mohamed
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | | | - Helena Blake
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Arun Shanmuganandan
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Waleed Albadry
- Plastics Surgery Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Julia Panascia
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - William Gray
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
| | - Stella Vig
- The Abdominal Wall Unit, Croydon University Hospital, Thornton Heath, London, UK
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Djukanovic M, Skrobic O, Stojakov D, Knezevic NN, Milicic B, Sabljak P, Simic A, Milenkovic M, Sreckovic S, Markovic D, Palibrk I. Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer. Front Med (Lausanne) 2024; 11:1366438. [PMID: 38770049 PMCID: PMC11102964 DOI: 10.3389/fmed.2024.1366438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
BackgroundEnhanced Recovery After Surgery (ERAS) protocol for esophagectomy may reduce the high incidence of postoperative morbidity and mortality. The aim of this study was to assess the impact of properly conducted ERAS protocol with specific emphasis on fluid balance and opioid-sparing anesthesia (OSA) on postoperative major morbidity and mortality after esophagectomy.MethodsPatients undergoing elective esophagectomy for esophageal cancer at the Hospital for Digestive Surgery, University Clinical Center of Serbia, from December 2017 to March 2021, were included in this retrospective observational study. Patients were divided into two groups: the ERAS group (OSA, intraoperative goal-directed therapy, and postoperative “near-zero” fluid balance) and the control group (opioid-based anesthesia, maintenance mean blood pressure ≥ 65 mmHg, and liberal postoperative fluid management). The primary outcome was major morbidity within 30 days from surgery and 30-day and 90-day mortality. Multivariable analysis was used to examine the effect of the ERAS protocol.ResultsA total of 121 patients were divided into the ERAS group (69 patients) and the control group (52 patients). Patients in the ERAS group was received less fentanyl, median 300 (interquartile range (IQR), 200–1,550) mcg than in control group, median 1,100 (IQR, 650–1750) mcg, p < 0.001. Median intraoperative total infusion was lower in the ERAS group, 2000 (IQR, 1000–3,750) mL compared to control group, 3,500 (IQR, 2000–5,500) mL, p < 0.001. However, intraoperative norepinephrine infusion was more administered in the ERAS group (52.2% vs. 7.7%, p < 0.001). On postoperative day 1, median cumulative fluid balance was 2,215 (IQR, −150-5880) mL in the ERAS group vs. 4692.5 (IQR, 1770–10,060) mL in the control group, p = 0.002. After the implementation of the ERAS protocol, major morbidity was less frequent in the ERAS group than in the control group (18.8% vs. 75%, p < 0.001). There was no statistical significant difference in 30-day and 90-day mortality (p = 0.07 and p = 0.119, respectively). The probability of postoperative major morbidity and interstitial pulmonary edema were higher in control group (OR 5.637; CI95%:1.178–10.98; p = 0.030 and OR 5.955; CI95% 1.702–9.084; p < 0.001, respectively).ConclusionA major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.
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Affiliation(s)
- Marija Djukanovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ognjan Skrobic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Stojakov
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Surgery Clinic, Clinical Centre “Dr. Dragisa Misovic – Dedinje”, Belgrade, Serbia
| | - Nebojsa Nick Knezevic
- Department of Anaesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
- Department of Anaesthesiology, College of Medicine, University of Illinois, Chicago, IL, United States
- Department of Surgery, College of Medicine, University of Illinois, Chicago, IL, United States
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Sabljak
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar Simic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Milenkovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology, Emergency Center, University Clinical Center of Serbia, Belgrade, Serbia
| | - Svetlana Sreckovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anesthesiology, Clinic for Orthopedics Surgery and Traumatology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Markovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiac Anesthesiology, Hospital of Cardiovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Palibrk
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
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Zacha S, Biernawska J. Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review. J Pers Med 2024; 14:411. [PMID: 38673038 PMCID: PMC11051180 DOI: 10.3390/jpm14040411] [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: 03/17/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.
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Affiliation(s)
- Sławomir Zacha
- Department of Pediatric Orthopedics and Oncology of Musculoskeletal System, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anesthesiology and Intensive Therapy, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland;
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11
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Wang D, Wang X, Wang Q, Xu Y, Xu Y. Comparative study of wound outcomes and surgical strategies: Internal fixation versus external stabilization in rib fracture patients with traumatic chest wounds. Int Wound J 2024; 21:e14548. [PMID: 38151911 PMCID: PMC10961044 DOI: 10.1111/iwj.14548] [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: 11/09/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 12/29/2023] Open
Abstract
The clinical management of traumatic chest incisions accompanied by rib fractures presents the formidable challenge. The study was carried out to compare the outcomes of auscultatory triangle internal fixation (ATIF) and external fixation (EF) in such injuries. From June 2019 to June 2022, 105 patients with multiple rib fractures participated in the cohort study in which they were divided into two groups: 53 patients underwent ATIF and 52 patients underwent EF. The incidence of surgical site infection, wound healing time, incidence of wound dehiscence, number of dressing changes, pain as measured by the visual analogue scale (VAS), duration of hospitalization, period of return to work, pulmonary complications and functionality of the upper limbs as assessed by the Disability of Arm, Shoulder, and Hand (DASH) questionnaire were among the parameters evaluated. In comparison with EF, ATIF demonstrated the decreased incidence of wound dehiscence (1.9% vs. 9.6%) (p < 0.05), surgical site infection (3.8 vs. 11.5) and wound healing time (12.3 ± 2.1 vs. 18.5 ± 3.7 days) (p < 0.05). Furthermore, during their ATIF treatment, patients required fewer changes of dressing (3.5 ± 0.8 vs. 5.7 ± 1.2) and demonstrated enhanced pain management, reduced hospital stays and expedited return to work (p < 0.05). ATIF group demonstrated enhancements in both upper limb functionality and post-operative pulmonary function (p < 0.05). The utilization of ATIF as opposed to EF for the treatment of traumatic chest wounds accompanied by rib fractures yields superior outcomes in terms of wound healing, infection reduction and restoration of pulmonary and upper limb functionality.
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Affiliation(s)
- Dongdong Wang
- Department of Thoracic Surgery, Shanghai Pudong HospitalFudan University Pudong Medical CenterShanghaiChina
| | - Xiaoqi Wang
- Department of Thoracic Surgery, Shanghai Pudong HospitalFudan University Pudong Medical CenterShanghaiChina
| | - Qingqing Wang
- Department of Thoracic Surgery, Shanghai Pudong HospitalFudan University Pudong Medical CenterShanghaiChina
| | - Yueping Xu
- Department of Thoracic Surgery, Shanghai Pudong HospitalFudan University Pudong Medical CenterShanghaiChina
| | - Yongdong Xu
- Department of Thoracic Surgery, Shanghai Pudong HospitalFudan University Pudong Medical CenterShanghaiChina
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12
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Lima LG, Sampaio BFC, Neves MAS, Barbosa AP, Seid VE, Lopes FDTQS. Implementation of the Fast-track Protocol for Total Hip Arthroplasty in a Public Hospital in the State of São Paulo - Brazil. Rev Bras Ortop 2024; 59:e297-e306. [PMID: 38606136 PMCID: PMC11006524 DOI: 10.1055/s-0043-1771489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/16/2022] [Indexed: 04/13/2024] Open
Abstract
Objective Evaluate the results of the implementation of the Fast Track Protocol (FTP), a medical practice based on scientific evidence, for elective total hip arthroplasty surgery, mainly comparing the National Average Hospital Admission Rate of 7.1 days. Methods 98 patients who underwent elective total hip arthroplasty surgery via the direct anterior approach, anterolateral approach and posterior approach were included in the FTP from December 2018 to March 2020, being followed up preoperatively, intraoperatively and immediately postoperatively. Results The average length of hospital stay was 2.8 days, being 2.1 days for the direct anterior approach, 3.0 days for the anterolateral access approach and 4.1 days for the posterior access approach. The average surgery time was 90 minutes, 19 (19.39%) of the patients were referred to the ICU in the postoperative period, however, none of them underwent surgery using the direct anterior approach. We had no cases of deep vein thrombosis (DVT), pulmonary embolism (PTE) or neurological injury, 19 (19.39%) patients had postoperative bleeding requiring dressing change, 4 (4.08%) needed blood transfusion, 2 (2.04%) patients had implant instability, 1 (1.02%) patient had a fracture during surgery and 1 (1.02%) patient died of cardiac complications. Conclusion FTP may be a viable alternative to reduce the length of stay and immediate postoperative complications for elective total hip arthroplasty surgery decreasing the length of stay of patients by 2 to 3 times when compared to the national average of 7.1 days.
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Affiliation(s)
- Leandro Gregorut Lima
- Arthron Serviços Médicos Especializados, São Paulo, SP, Brasil
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Hospital Regional de São José dos Campos, Instituto Sócrates Guanaes, São José dos Campos, SP, Brasil
| | | | - Marco Aurélio Silvério Neves
- Arthron Serviços Médicos Especializados, São Paulo, SP, Brasil
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Hospital Regional de São José dos Campos, Instituto Sócrates Guanaes, São José dos Campos, SP, Brasil
| | - Alexandre Póvoa Barbosa
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Hill AG, Jin J. Enhanced recovery after surgery: an update for the generalist. Med J Aust 2024; 220:229-230. [PMID: 38311817 DOI: 10.5694/mja2.52224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Andrew G Hill
- Te Whatu Ora Counties Manukau, University of Auckland, Auckland, New Zealand
| | - James Jin
- Te Whatu Ora Counties Manukau, University of Auckland, Auckland, New Zealand
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14
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Yadav P, Chaudhari K, Dave A, Sindhu A. Exploring the Evolution of Robotic Surgery in Obstetrics and Gynecology: Past, Present, and Future Perspectives. Cureus 2024; 16:e57155. [PMID: 38681448 PMCID: PMC11055614 DOI: 10.7759/cureus.57155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Robotic surgery has emerged as a transformative technology in obstetrics and gynecology, offering enhanced precision and minimally invasive techniques for various procedures. This paper explores the evolution of robotic surgery in obstetrics and gynecology, examining its historical development, current applications, and prospects. Through a comprehensive review of the literature and case studies, we highlight the benefits of robotic surgery, including reduced trauma, improved patient outcomes, and increased surgeon capabilities. However, cost, training requirements, and regulatory concerns hinder widespread adoption. Continuing technological innovation is expected to enhance the efficacy and applicability of robotic-assisted procedures. Collaboration between healthcare professionals, researchers, and industry stakeholders is essential to address these challenges and ensure optimal patient care. By embracing the opportunities presented by robotic surgery while addressing associated challenges, practitioners and researchers can contribute to the continued advancement of this transformative technology in obstetrics and gynecology.
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Affiliation(s)
- Pallavi Yadav
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kamlesh Chaudhari
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Apoorva Dave
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arman Sindhu
- Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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15
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Ricci C, Alberici L, Serbassi F, Caraceni P, Domenicali M, Ingaldi C, Grego DG, Mazzucchelli C, Casadei R. Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach. Ann Surg Oncol 2024; 31:1725-1738. [PMID: 38038791 PMCID: PMC10838229 DOI: 10.1245/s10434-023-14632-8] [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: 07/18/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes. METHODS A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia. RESULTS The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27). CONCLUSIONS Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy.
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Francesco Serbassi
- Alma Mater Studiorum, Biology of the Health Faculty, University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Marco Domenicali
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, AUSL Romagna, "S. Maria Delle Croci" Hospital, Ravenna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Davide Giovanni Grego
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Alma Mater Studiorum, Biology of the Health Faculty, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, AUSL Romagna, "S. Maria Delle Croci" Hospital, Ravenna, Italy
| | - Carlo Mazzucchelli
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Grant MC, Salenger R, Lobdell KW. Perioperative hemodynamic monitoring in cardiac surgery. Curr Opin Anaesthesiol 2024; 37:1-9. [PMID: 38085877 DOI: 10.1097/aco.0000000000001327] [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: 12/20/2023]
Abstract
PURPOSE OF REVIEW Cardiac surgery has traditionally relied upon invasive hemodynamic monitoring, including regular use of pulmonary artery catheters. More recently, there has been advancement in our understanding as well as broader adoption of less invasive alternatives. This review serves as an outline of the key perioperative hemodynamic monitoring options for cardiac surgery. RECENT FINDINGS Recent study has revealed that the use of invasive monitoring such as pulmonary artery catheters or transesophageal echocardiography in low-risk patients undergoing low-risk cardiac surgery is of questionable benefit. Lesser invasive approaches such a pulse contour analysis or ultrasound may provide a useful alternative to assess patient hemodynamics and guide resuscitation therapy. A number of recent studies have been published to support broader indication for these evolving technologies. SUMMARY More selective use of indwelling catheters for cardiac surgery has coincided with greater application of less invasive alternatives. Understanding the advantages and limitations of each tool allows the bedside clinician to identify which hemodynamic monitoring modality is most suitable for which patient.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina, USA
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17
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Huang LW, Zhong Y. Endoscopic submucosal dissection vs transanal endoscopic surgery for rectal tumors: A systematic review and meta-analysis. World J Clin Cases 2024; 12:95-106. [PMID: 38292620 PMCID: PMC10824170 DOI: 10.12998/wjcc.v12.i1.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) and transanal endoscopic submucosal dissection (TES) are widely employed surgical techniques. However, the comparative efficacy and safety of both remain inconclusive. AIM To comprehensively analyze and discern differences in surgical outcomes between ESD and TES. METHODS We conducted a systematic search of the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus, and CINAHL from inception till August 2023. We analyzed outcomes including recurrence rate, en bloc resection, R0 resection rate, perforation rate, procedure length, and hospital stay length applying a random-effects inverse-variance model. We assessed publication bias by conducting an Egger's regression test and sensitivity analyses. RESULTS We pooled data from 11 studies involving 1013 participants. We found similar recurrence rates, with a pooled odds ratio of 0.545 (95%CI: 0.176-1.687). En bloc resection, R0 resection, and perforation rate values were also similar for both ESD and TES. The pooled analysis for procedure length indicated a mean difference of -4.19 min (95%CI: -22.73 to 14.35), and the hospital stay was on average shorter for ESDs by about 0.789 days (95%CI: -1.671 to 0.093). CONCLUSION Both ESD and TES displayed similar efficacy and safety profiles across multiple outcomes. Our findings show that individualized patient and surgeon preferences, alongside specific clinical contexts, can be considered when selecting between these two techniques.
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Affiliation(s)
- Long-Wu Huang
- Department of Gastroenterology, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
| | - Ying Zhong
- Department of Gastroenterology, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
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18
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Wang B, Kou X. Effect of accelerated rehabilitation nursing programmes on surgical site wound infection in patients undergoing laparoscopic cholecystectomy: A meta-analysis. Int Wound J 2024; 21:e14346. [PMID: 37592759 PMCID: PMC10781593 DOI: 10.1111/iwj.14346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/21/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023] Open
Abstract
This study aims to evaluate the effect of an accelerated rehabilitation nursing programme on the incidence of surgical site wound infections in patients undergoing laparoscopic cholecystectomy. Relevant studies regarding the use of an accelerated rehabilitation nursing programme in laparoscopic cholecystectomy were retrieved from databases, including PubMed, Web of Science, the Cochrane Library, EMBASE, CNKI and Wanfang Database. The search was conducted from the inception of each database until June 2023. Two independent researchers performed the literature screening, data collection and quality assessment of the included studies. Odds ratio (OR) and 95% confidence interval (CI) were used as the measures of effect. Statistical analysis was conducted using Stata 17.0, and a sensitivity analysis and publication bias evaluation were performed. A total of 21 studies involving 2480 patients (1179 in the intervention group and 1301 in the control group) were included. The meta-analysis revealed that the incidence of surgical site wound infections in the intervention group was significantly lower than in the control group (1.18% vs. 5.99%, OR: 0.322, 95% CI: 0.168-0.556, p < 0.001). Current evidence suggests that implementing accelerated rehabilitation nursing programmes for patients undergoing laparoscopic cholecystectomy has a clinically significant effect, leading to a substantial reduction in the incidence of surgical site wound infections. However, owing to the low quality of some of the included studies, further high-quality, multicentre, large-sample randomised controlled trials are required to validate the conclusions of this study.
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Affiliation(s)
- Bei Wang
- Department of Internal Medicine of Abdominal Oncology, Hubei Cancer Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiao‐Ling Kou
- Department of Hepatobiliary and Pancreatic Surgery, Hubei Cancer Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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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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Lersch F, Correia PC, Hight D, Kaiser HA, Berger-Estilita J. The nuts and bolts of multimodal anaesthesia in the 21st century: a primer for clinicians. Curr Opin Anaesthesiol 2023; 36:666-675. [PMID: 37724595 PMCID: PMC10621648 DOI: 10.1097/aco.0000000000001308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW This review article explores the application of multimodal anaesthesia in general anaesthesia, particularly in conjunction with locoregional anaesthesia, specifically focusing on the importance of EEG monitoring. We provide an evidence-based guide for implementing multimodal anaesthesia, encompassing drug combinations, dosages, and EEG monitoring techniques, to ensure reliable intraoperative anaesthesia while minimizing adverse effects and improving patient outcomes. RECENT FINDINGS Opioid-free and multimodal general anaesthesia have significantly reduced opioid addiction and chronic postoperative pain. However, the evidence supporting the effectiveness of these approaches is limited. This review attempts to integrate research from broader neuroscientific fields to generate new clinical hypotheses. It discusses the correlation between high-dose intraoperative opioids and increased postoperative opioid consumption and their impact on pain indices and readmission rates. Additionally, it explores the relationship between multimodal anaesthesia and pain processing models and investigates the potential effects of nonpharmacological interventions on preoperative anxiety and postoperative pain. SUMMARY The integration of EEG monitoring is crucial for guiding adequate multimodal anaesthesia and preventing excessive anaesthesia dosing. Furthermore, the review investigates the impact of combining regional and opioid-sparing general anaesthesia on perioperative EEG readings and anaesthetic depth. The findings have significant implications for clinical practice in optimizing multimodal anaesthesia techniques (Supplementary Digital Content 1: Video Abstract, http://links.lww.com/COAN/A96 ).
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Affiliation(s)
- Friedrich Lersch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern
| | - Paula Cruz Correia
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern
| | - Darren Hight
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern
| | - Heiko A. Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern
- Centre for Anaesthesiology and Intensive Care, Hirslanden Klink Aarau, Hirslanden Medical Group, Schaenisweg, Aarau
| | - Joana Berger-Estilita
- Institute of Anesthesiology and Intensive Care, Salemspital, Hirslanden Medical Group
- Institute for Medical Education, University of Bern, Bern, Switzerland
- CINTESIS@RISE, Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
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Ricci C, Serbassi F, Alberici L, Ingaldi C, Gaetani L, De Raffele E, Pironi L, Sasdelli AS, Mosconi C, Di Marco MC, Casadei R. Immunonutrition in patients who underwent major abdominal surgery: A comprehensive systematic review and component network metanalysis using GRADE and CINeMA approaches. Surgery 2023; 174:1401-1409. [PMID: 37775395 DOI: 10.1016/j.surg.2023.08.005] [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: 04/02/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The benefits of immunonutrition in patients who underwent major abdominal surgery have been recently established, but the optimal combination of immunonutrients has remained unclear. The aim is to clarify this point. METHODS A systematic search of randomized clinical trials about immunonutrition in major abdominal surgery was made. A frequentist random-effects component network meta-analysis was conducted, reporting the P score and odds ratio or mean difference with a 95% confidence interval. The best components and best plausible strategies were described. The critical endpoints were morbidity and mortality rates. The important endpoints were infectious complication rate and length of stay. RESULTS The meta-analysis includes 87 studies and 8,375 patients. The best approach for morbidity rate, with a moderate grade of certainty, was the use of perioperative enteral/oral immunonutrition with arginine, glutamine, and polyunsaturated fatty acids (odds ratio 0.32; 0.10 to 0.98; P score of 0.93). The mortality rate was reduced by postoperative enteral immunonutrition with RNA, arginine, and polyunsaturated fatty acids (odds ratio 59; 0.29 to 1.22; P score 0.84) but with a low grade of certainty. No significant heterogeneity or incoherence is observed. The length of stay and infectious results are "at risk" for high heterogeneity or network meta-analysis incoherence. The component analysis confirmed that postoperative oral/enteral use of 2 or 3 components is crucial to reducing morbidity rate. CONCLUSION The oral/enteral immunonutrition in the postoperative period, with multiple immunonutrients, can reduce the morbidity rate in patients undergoing major abdominal surgery. The effect of immunonutrition on mortality, infectious disease, and length of stay is unclear.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy; Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Italy.
| | - Francesco Serbassi
- Biology of the Health Faculty, Alma Mater Studiorum, University of Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Luca Gaetani
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Italy
| | - Emilio De Raffele
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Loris Pironi
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit, Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Anna Simona Sasdelli
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit, Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Cristina Mosconi
- Division of Interventional Radiology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy
| | - Maria Cristina Di Marco
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy; Department of Specialized, Diagnostic, and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Italy; Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Italy
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Meyrat R, Vivian E, Sridhar A, Gulden RH, Bruce S, Martinez A, Montgomery L, Reed DN, Rappa PJ, Makanbhai H, Raney K, Belisle J, Castellanos S, Cwikla J, Elzey K, Wilck K, Nicolosi F, Sabat ME, Shoup C, Graham RB, Katzen S, Mitchell B, Oh MC, Patel N. Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review. Medicine (Baltimore) 2023; 102:e36142. [PMID: 38013300 PMCID: PMC10681460 DOI: 10.1097/md.0000000000036142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023] Open
Abstract
The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.
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Affiliation(s)
- Richard Meyrat
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Elaina Vivian
- Performance Improvement, Methodist Dallas Medical Center, Dallas, TX
| | - Archana Sridhar
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - R. Heath Gulden
- Anesthesia Consultants of Dallas Division, US Anesthesia Partners, Dallas, TX
| | - Sue Bruce
- Clinical Outcomes Management, Methodist Dallas Medical Center, Dallas, TX
| | - Amber Martinez
- Pre-Surgery Assessment, Methodist Dallas Medical Center, Dallas, TX
| | - Lisa Montgomery
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Donald N. Reed
- Neurosurgery Division, Methodist Health System, Dallas, TX
| | | | | | | | | | - Stacey Castellanos
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Judy Cwikla
- Neurocritical Care Unit, Methodist Dallas Medical Center, Dallas, TX
| | - Kristin Elzey
- Pharmacy, Methodist Dallas Medical Center, Dallas, TX
| | - Kristen Wilck
- Clinical Nutrition, Methodist Dallas Medical Center, Dallas, TX
| | - Fallon Nicolosi
- Methodist Community Pharmacy – Dallas, Methodist Dallas Medical Center, Dallas, TX
| | - Michael E. Sabat
- Surgery and Recovery, Methodist Dallas Medical Center, Dallas, TX
| | - Chris Shoup
- Executive Office, Methodist Health System, Dallas, TX
| | - Randall B. Graham
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Stephen Katzen
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Bartley Mitchell
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Michael C. Oh
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Nimesh Patel
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
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Tao D, Awan-Scully R, Ash GI, Gu Y, Pei Z, Gao Y, Cole A, Supriya R, Sun Y, Xu R, Baker JS. Health policy considerations for combining exercise prescription into noncommunicable diseases treatment: a narrative literature review. Front Public Health 2023; 11:1219676. [PMID: 37849722 PMCID: PMC10577435 DOI: 10.3389/fpubh.2023.1219676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Objectives In this review, we aim to highlight the evidence base for the benefits of exercise in relation to the treatment of noncommunicable diseases (NCDs), draw on the Health Triangular Policy Framework to outline the principal facilitators and barriers for implementing exercise in health policy, and make concrete suggestions for action. Methods Literature review and framework analysis were conducted to deal with the research questions. Results Exercise prescription is a safe solution for noncommunicable diseases prevention and treatment that enables physicians to provide and instruct patients how to apply exercise as an important aspect of disease treatment and management. Combining exercise prescription within routine care, in inpatient and outpatient settings, will improve patients' life quality and fitness levels. Conclusion Inserting exercise prescription into the healthcare system would improve population health status and healthy lifestyles. The suggestions outlined in this study need combined efforts from the medical profession, governments, and policymakers to facilitate practice into reality in the healthcare arena.
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Affiliation(s)
- Dan Tao
- Faculty of Sports Science, Ningbo University, Ningbo, China
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo, China
- Department of Government and International Studies, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Roger Awan-Scully
- Department of Government and International Studies, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Garrett I. Ash
- Section of General Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, United States
- Center for Pain, Research, Informatics, Medical Comorbidities and Education Center (PRIME), VA Connecticut Healthcare System, West Haven, CT, United States
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo, China
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo, China
| | - Zhong Pei
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Gao
- Department of Sports, Physical Education and Health, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Alistair Cole
- Department of Government and International Studies, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Rashmi Supriya
- Department of Sports, Physical Education and Health, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Yan Sun
- Department of Sports, Physical Education and Health, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
| | - Rui Xu
- School of Sports and Health, Nanjing Sport Institute, Nanjing, China
| | - Julien S. Baker
- Faculty of Sports Science, Ningbo University, Ningbo, China
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo, China
- Centre for Health and Exercise Science Research, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
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Ricci C, Serbassi F, Alberici L, Ingaldi C, Eusebi LH, De Raffele E, Pironi L, Sasdelli AS, Mosconi C, Vicennati V, Casadei R. Value of immunonutrition in patients undergoing pancreatic resection: a trial sequential meta-analysis. HPB (Oxford) 2023; 25:1151-1160. [PMID: 37328364 DOI: 10.1016/j.hpb.2023.03.014] [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: 08/25/2022] [Revised: 01/19/2023] [Accepted: 03/23/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The benefits of immunonutrition (IM) in patients who underwent pancreatic surgery are unclear. METHODS A meta-analysis of randomized clinical trials (RCTs) comparing IM with standard nutrition (SN) in pancreatic surgery was carried out. A random-effects trial sequential meta-analysis was made, reporting Risk Ratio (RR), mean difference (MD), and required information size (RIS). If RIS was reached, false negative (type II error) and positive results (type I error) could be excluded. The endpoints were morbidity, mortality, infectious complication, postoperative pancreatic fistula (POPF) rates, and length of stay (LOS). RESULTS The meta-analysis includes 6 RCTs and 477 patients. Morbidity (RR 0.77; 0.26 to 2.25), mortality (RR 0.90; 0.76 to 1.07), and POPF rates were similar. The RISs were 17,316, 7,417, and 464,006, suggesting a type II error. Infectious complications were lower in the IM group, with a RR of 0.54 (0.36-0.79; 95 CI). The LOS was shorter in IM (MD -0.3 days; -0.6 to -0.1). For both, the RISs were reached, excluding type I error. CONCLUSION The IM can reduce infectious complications and LOS The small differences in mortality, morbidity, and POPF make it impossible to exclude type II error due to large RISs.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy.
| | - Francesco Serbassi
- Grad Student in Biology of the Health Faculty, Alma Mater Studiorum, University of Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Leonardo H Eusebi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Division of Gastroenterology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Emilio De Raffele
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Loris Pironi
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit - Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Anna S Sasdelli
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit - Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Cristina Mosconi
- Division of Interventional Radiology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Valentina Vicennati
- Division of Endocrinology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
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25
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McKechnie T, Parpia S, Bhandari M, Dionne JC, Eskicioglu C. Enhanced Recovery After Surgery (ERAS) protocols following emergency intra-abdominal surgery: A systematic review and meta-analysis protocol. PLoS One 2023; 18:e0291140. [PMID: 37682876 PMCID: PMC10490890 DOI: 10.1371/journal.pone.0291140] [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] [Received: 03/02/2023] [Accepted: 07/24/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis is to evaluate whether the implementation of Enhanced Recovery After Surgery (ERAS) protocols for adult patients undergoing emergency intra-abdominal surgery decreases postoperative length of stay, postoperative morbidity, and mortality compared to conventional perioperative care. METHODS A systematic review and meta-analysis will be performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). It has been registered on the International Prospective Register for Systematic Reviews (PROSPERO; CRD42023391709). A comprehensive, electronic search strategy will be used to identify studies published and indexed in MEDLINE, EMBASE, Web of Science, CENTRAL, and Pubmed databases since their inception. Trial registries and references of included studies and pertinent previous systematic reviews will also be searched. Studies will be included if they are randomized controlled trials or cohort studies evaluating adult patients undergoing emergency intra-abdominal surgery and comparing ERAS or modified ERAS protocols to conventional perioperative care and report one of the following outcomes: postoperative length of stay, overall 30-day morbidity, 30-day mortality, 30-day infectious morbidity, prolonged postoperative ileus, return of bowel function, and 30-day readmissions. A meta-analysis will be performed using a random effects model for all comparative data using Cochrane Review Manager 5.3 (London, United Kingdom). DISCUSSION ERAS protocols have become standard of care for patients undergoing elective surgery. Their use in the setting of emergency surgery is far less common. The aim of this systematic review and meta-analysis is to assess whether there are benefits in patient important outcomes with the implementation of ERAS protocols for patients undergoing emergency intra-abdominal surgery. Ultimately, we hope to promote their use and further large randomized controlled trials evaluating emergency surgery ERAS programs. PROSPERO REGISTRATION NUMBER CRD42023391709.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Joanna C. Dionne
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada
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26
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Porserud A, Aly M, Nygren-Bonnier M, Hagströmer M. Association between early mobilisation after abdominal cancer surgery and postoperative complications. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106943. [PMID: 37296020 DOI: 10.1016/j.ejso.2023.05.018] [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: 03/15/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Postoperative complications and readmission to hospital after major cancer surgery are common. Early mobilisation in hospital is thought to reduce complications, and patients are recommended to mobilise for at least 2 h on the day of surgery, and thereafter at least 6 h per day. Evidence for early mobilisation is limited and therefore also how early mobilisation may influence the development of postoperative complications. The aim of this study was to evaluate the association between early mobilisation after abdominal cancer surgery and readmission to hospital due to postoperative complications. MATERIAL AND METHODS Adult patients who had abdominal cancer surgery due to ovarian, colorectal, or urinary bladder cancer between January 2017 and May 2018 were included in the study. Exposure was set to the mean number of steps taken over the first three postoperative days, measured with an activity monitor. Primary outcome was readmission to hospital within 30 days after discharge, and secondary outcome was severity of complications. Data were obtained from medical records. Logistic regression was used to investigate the association between exposure and outcomes. RESULTS Of 133 patients included in the study, 25 were readmitted to the hospital within 30 days after discharge. The analysis showed no association between early mobilisation and readmission or severity of complications. CONCLUSION Early mobilisation does not seem to increase the odds of readmission, nor the severity of complications. This study contributes to the limited research on the association between early mobilisation and postoperative complications after abdominal cancer surgery.
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Affiliation(s)
- Andrea Porserud
- Karolinska Institutet, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden; Karolinska University Hospital, Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, 171 76, Stockholm, Sweden.
| | - Markus Aly
- Karolinska Institutet, Department of Molecular Medicine and Surgery, 171 77, Stockholm, Sweden; Karolinska University Hospital, Patient Area Pelvic Cancer, Theme Cancer, 171 76, Stockholm, Sweden.
| | - Malin Nygren-Bonnier
- Karolinska Institutet, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden; Karolinska University Hospital, Medical Unit Occupational Therapy and Physiotherapy, Women's Health and Allied Health Professionals Theme, 171 76, Stockholm, Sweden.
| | - Maria Hagströmer
- Karolinska Institutet, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Alfred Nobels Allé 23, 23100, 141 83, Huddinge, Sweden; Academic Primary Health Care Centre, Region Stockholm, 113 65, Stockholm, Sweden; Sophiahemmet University, Department of Health Promoting Science, 114 28, Stockholm, Sweden.
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Abhinav K, Jadhav D, Andar UB, Karmarkar V, Agrawal R, Agrawal A. Management of Post-craniotomy Pain in Elective Cases: A Randomized Controlled Trial. Cureus 2023; 15:e46189. [PMID: 37905293 PMCID: PMC10613341 DOI: 10.7759/cureus.46189] [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: 07/22/2023] [Accepted: 09/28/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Craniotomy is associated with significant postoperative discomfort. Standardized pain management and enhanced recovery after surgery (ERAS) protocol could improve patient-reported outcomes and lower medical expenses. AIM The aim of this study is to prospectively assess the effectiveness of an ERAS protocol for neurosurgery in the treatment of postoperative pain following elective craniotomies. METHODS AND MATERIALS A total of 128 patients were assigned to the ERAS group and received care in accordance with the neurosurgical ERAS regulations, while 130 other participants were assigned to the control group and received traditional postoperative assistance. The participants' postoperative pain ratings using the numerical rating scale (NRS) were this study's main outcome of interest. The verbal NRS uses the numbers 0 to 10, with 0 indicating no sensation of pain and 10 indicating the most severe pain. On postoperative day (POD) 1, the patients' postoperative pain level at the surgical site was evaluated using the NRS. This was repeated every day until the patient either reported feeling no sensation of pain or was discharged home. RESULTS The mean value of pain on the day of surgery was 4.43 ± 0.43 and 4.72 ± 0.68 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. However, the difference was not statistically significant (p = 0.478). The mean value of pain on POD1 was 3.13 ± 0.21 and 4.45 ± 0.95 for patients in the ERAS and control groups, respectively. These pain values were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.011). The mean value of pain on POD2 was 2.86 ± 0.3 and 4.33 ± 0.37 for patients in the ERAS and control groups, respectively. The values of pain were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.003). The mean value of pain on POD3 was 2.33 ± 0.52 and 4.04 ± 0.15 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. The difference was meaningful statistically (p < 0.001). The mean value of pain on POD4 was 2.26 ± 0.9 and 2.84 ± 0.13 for the ERAS and control groups, respectively. However, the difference was not statistically significant (p = 0.274). The ERAS group had a significantly higher proportion of participants rating their pain between 1 and 3 (68.9%) and a lower proportion rating their pain between 4 and 7 (28.2%), compared to the control group (p < 0.001). Differences in the highest pain ratings (8-10) between the groups were not statistically significant. The duration of hospital stay, beginning from surgery to discharge, was lesser among study participants in the ERAS group, and this finding was statistically significant (p < 0.001). CONCLUSION The findings of this study imply that the ERAS protocol may aid pain management following elective craniotomies. Additionally, the ERAS protocol decreased the overall expense of medical care and the cumulative/postoperative length of hospital stay.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Lilavati Hospital and Research Centre, Mumbai, IND
| | - Dikpal Jadhav
- Department of Neurosurgery, King Edward Memorial (KEM) Hospital, Mumbai, IND
| | - Uday B Andar
- Department of Neurosurgery, Bai Jerbai Wadia Hospital for Children, Mumbai, IND
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital and Medical Research Centre, Mumbai, IND
| | - Rama Agrawal
- Department of Physiology, Patna Medical College and Hospital, Patna, IND
| | - Ankita Agrawal
- Department of Conservative and Endodontics, Buddha Institute of Dental Sciences & Hospital, Patna, IND
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Cukierman DS, Cata JP, Gan TJ. Enhanced recovery protocols for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:285-303. [PMID: 37938077 DOI: 10.1016/j.bpa.2023.04.007] [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: 01/03/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.
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Affiliation(s)
- Daniel S Cukierman
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Tong Joo Gan
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
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29
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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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Rowley A, Adiamah A, Kushairi A, Lewis SJ, Lobo DN. The effect of post-discharge oral nutritional supplements on outcomes after gastrointestinal surgery: A systematic review and meta-analysis. Clin Nutr 2023; 42:1189-1201. [PMID: 37244753 DOI: 10.1016/j.clnu.2023.04.028] [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: 01/27/2023] [Accepted: 04/29/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Malnutrition is a risk-factor for adverse postoperative outcomes. This systematic review and meta-analysis evaluated the impact of post-discharge oral nutritional supplements (ONS) on outcomes in patients undergoing gastrointestinal surgery. METHODS The Medline and Embase databases were searched for randomised clinical trials in patients undergoing gastrointestinal surgery who had received ONS for at least two weeks after discharge from hospital. The primary endpoint was weight change. Secondary endpoints included quality of life, total lymphocyte count, total serum protein and serum albumin. Analysis was performed using RevMan5.4 software. RESULTS Fourteen studies with 2480 participants (1249 ONS/1231 controls) were included. Pooling of results revealed that a reduction in postoperative weight loss in patients taking ONS, when compared with control: overall weighted mean difference (WMD) -1.69 kg, 95% CI -2.98 to -0.41, P = 0.01. Serum albumin concentration was increased in the ONS group: WMD = 1.06 g/L, 95% CI 0.04 to 2.07, P = 0.04. Haemoglobin was also increased: WMD = 2.91 g/L, 95% CI 0.58 to 5.25, P = 0.01. Total serum protein, total lymphocyte count, total cholesterol and quality of life did not differ between the groups. Patient compliance was relatively poor across the studies and there was variability in the composition of ONS, volume consumed and surgical procedures performed. CONCLUSIONS There was a reduction in postoperative weight loss and an improvement in some biochemical parameters in patients receiving ONS after gastrointestinal surgery. Future RCTs with more consistent methodologies are needed to investigate the efficacy of ONS after discharge from hospital following gastrointestinal surgery.
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Affiliation(s)
- Annabel Rowley
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Anisa Kushairi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Stephen J Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Uday Bhaskar MNS, Sundararajan L. Feasibility of Enhanced Recovery after Surgery in Pediatric Colostomy Reversal. J Indian Assoc Pediatr Surg 2023; 28:319-324. [PMID: 37635895 PMCID: PMC10455705 DOI: 10.4103/jiaps.jiaps_107_22] [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: 08/08/2022] [Revised: 03/26/2023] [Accepted: 04/06/2023] [Indexed: 08/29/2023] Open
Abstract
Aim Enhanced recovery after surgery (ERAS) are multimodal perioperative pathways that have shown improved outcomes. ERAS after colostomy reversal has shown promising results in adults and few pediatric studies. We report our experience using ERAS for a colostomy reversal. Materials and Methods A retrospective analysis of children in whom ERAS was used during colostomy reversal between May 2016 and 2019 was carried out. ERAS protocol in our study included avoiding mechanical bowel preparation (MBP), oral liquid diet upto 3 h preoperatively, usage of regional anesthesia, minimal handling of bowel intraoperatively, using nonopioid analgesics for pain relief, early initiation of feeding on the first postoperative day, early discharge once full feeds are established. Outcomes analyzed are the duration of hospital stay and complications, including readmissions. Requirement for opioids and anti-emetics are noted. The outcomes are compared with traditional care pathways (TCP), which use MBP, overnight fasting, opioid analgesia, and delayed feeding. A total of 48 are included in the study, with 13 cases using ERAS and TCP in 35 cases. Statistical Analysis Used Nonparametric Mann-Whitney U-test was used. Results In the ERAS group, the mean length of hospital stay (LOS) postoperatively was 3.7 days (2-5 days) as opposed to 7.2 days (5-11 days) in TCP. There was only one child with complications in the ERAS group, while 9 cases in TCP had complications, though none of them required operative intervention. There was the requirement of anti-emetic in only one child in the ERAS group. Conclusion ERAS for colostomy reversal is feasible in the pediatric population. For successful implementation, all personnel involved in the care of the child need to be educated about the protocol. It reduces LOS and complications.
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Affiliation(s)
- M. N. S. Uday Bhaskar
- Department of Paediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
| | - Lakshmi Sundararajan
- Department of Paediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
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Nørskov AK, Jakobsen JC, Afshari A, Bisgaard J, Geisler A, Hägi-Pedersen D, Lange KHW, Lundstrøm LH, Lunn TH, Maagaard M, Møller AM, Nedergaard HK, Nikolajsen L, Olsen MH, Juhl-Olsen P, Rasmussen BS, Vested M, Vester-Andersen M, Wikkelsø A, Mathiesen O. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA): A consortium initiative for perioperative research. Acta Anaesthesiol Scand 2023; 67:804-810. [PMID: 36922719 DOI: 10.1111/aas.14235] [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: 02/07/2023] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence-based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to (1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and (2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence-based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, for example, with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well-functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient-focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour-saving.
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Affiliation(s)
- Anders Kehlet Nørskov
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Jannie Bisgaard
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospital, Slagelse, Denmark
| | - Kai Henrik Wiborg Lange
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ann Merete Møller
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Herlev Anaesthesia Critical and Emergency Care Science Unit, Department of Anaesthesiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Cochrane Anaesthesia Group and Cochrane Emergency and Critical Care Group, Copenhagen, Denmark
| | - Helene Korvenius Nedergaard
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Intensive Care University Hospital of Southern Denmark, Kolding, Denmark
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic- and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Matias Vested
- Department of Anaesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Herlev Anaesthesia Critical and Emergency Care Science Unit, Department of Anaesthesiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Anne Wikkelsø
- Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Turaga AH. Enhanced Recovery After Surgery (ERAS) Protocols for Improving Outcomes for Patients Undergoing Major Colorectal Surgery. Cureus 2023; 15:e41755. [PMID: 37575751 PMCID: PMC10416136 DOI: 10.7759/cureus.41755] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have gained recognition as a perioperative care approach for patients undergoing major colorectal surgery. This systematic review aims to evaluate the effects of ERAS protocols on outcomes in this patient population. A systematic search was conducted in PubMed, Cochrane Library, and Embase databases for studies published between January 2010 and September 2021. Inclusion criteria encompassed studies assessing the impact of ERAS protocols on patients undergoing major colorectal surgery. Data were extracted, and a qualitative synthesis of the included studies was performed. A total of 18 studies met the inclusion criteria. The implementation of ERAS protocols was associated with several positive outcomes. Compared to traditional care, ERAS protocols significantly reduced the length of hospital stay (mean difference [MD]: -1.64 days, 95% confidence interval [CI]: -2.21 to -1.08, p<0.00001), postoperative complications (odds ratio [OR]: 0.57, 95% CI: 0.46 to 0.71, p<0.00001), and readmission rates (OR: 0.57, 95% CI: 0.38 to 0.85, p=0.006). ERAS protocols also led to a shorter time to return of bowel function (MD: -0.74 days, 95% CI: -1.03 to -0.45, p<0.00001), time to first mobilization (MD: -0.55 days, 95% CI: -0.82 to -0.28, p<0.0001), and time to first oral intake (MD: -0.62 days, 95% CI: -0.95 to -0.28, p=0.0003). Additionally, patients reported higher satisfaction levels with the implementation of ERAS protocols (MD: 1.02, 95% CI: 0.19 to 1.86, p=0.02). This systematic review demonstrates that the implementation of ERAS protocols in major colorectal surgery is associated with improved outcomes. ERAS protocols lead to reduced hospital stays, lower postoperative complications, and decreased readmission rates. Furthermore, they facilitate faster recovery of bowel function, mobilization, and oral intake. Patients also express higher satisfaction levels with ERAS implementation. Healthcare providers should consider adopting ERAS protocols to optimize perioperative care in patients undergoing major colorectal surgery.
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Affiliation(s)
- Anjani H Turaga
- Medicine and Surgery, Gandhi Medical College, Hyderabad, IND
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Szabó M, Pleck AP, Soós SÁ, Keczer B, Varga B, Széll J. A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study. Perioper Med (Lond) 2023; 12:30. [PMID: 37370150 DOI: 10.1186/s13741-023-00320-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension. METHODS Randomised controlled study in a tertiary university department involves elective surgical patients of ASA 2-3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40-40 patients; 38-38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0-10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h. RESULTS The absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00-4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups. CONCLUSION We implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care. TRIAL REGISTRATION The study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).
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Affiliation(s)
- Marcell Szabó
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
| | | | - Sándor Árpád Soós
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Balázs Varga
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - János Széll
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
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Ioannidis O, Ramirez JM, Ubieto JM, Feo CV, Arroyo A, Kocián P, Sánchez-Guillén L, Bellosta AP, Whitley A, Enguita AB, Teresa M, Anestiadou E. The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care. J Clin Med 2023; 12:4185. [PMID: 37445224 DOI: 10.3390/jcm12134185] [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: 04/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023] Open
Abstract
Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.
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Affiliation(s)
- Orestis Ioannidis
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
| | - Jose M Ramirez
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Surgery, Faculty of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Javier Martínez Ubieto
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Carlo V Feo
- Department of Surgery, Azienda Unità Sanitaria Locale Ferrara-University of Ferrara, 44121 Ferrara, Italy
| | - Antonio Arroyo
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Petr Kocián
- Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, 150 06 Prague, Czech Republic
| | - Luis Sánchez-Guillén
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Ana Pascual Bellosta
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Adam Whitley
- Department of Surgery, University Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | | | - Marta Teresa
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
| | - Elissavet Anestiadou
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
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Huang EY, Li JZ, Chung D, Jacobsen GR, Sandler BJ, Wadhwa A, Said E, Robbins K, Horgan S, Broderick RC. Carbohydrate Loading and Aspiration Risk in Bariatric Patients: Safety in Preoperative Enhanced Recovery Protocols. J Am Coll Surg 2023; 236:1200-1206. [PMID: 36804320 DOI: 10.1097/xcs.0000000000000665] [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: 02/23/2023]
Abstract
BACKGROUND Enhanced recovery protocols have been developed to improve perioperative outcomes; however, there is ongoing concern for aspiration with recent oral intake in patients with obesity, who may be predisposed to impaired gastrointestinal motility and greater gastric volumes. We aim to study the safety of a 300-mL preoperative carbohydrate-loading drink preceding bariatric surgery. STUDY DESIGN Data were collected prospectively from patients undergoing primary bariatric surgery. All bariatric patients at our institution are prescribed a proton pump inhibitor for 4 weeks before surgery and undergo a screening preoperative esophagogastroduodenoscopy (EGD) before surgery with a traditional 8-hour fast (NOCARB), followed by an intraoperative day-of-operation EGD with carbohydrate loading (CARB) 2 to 4 hours before incision. Gastric volumes and pH are measured after being endoscopically suctioned via direct visualization during both settings. RESULTS We identified 203 patients: 94 patients (46.3%) in the CARB group and 109 patients (53.7%) in the NOCARB group. The patients were 82.3% female with a mean age of 42.8 years and average BMI of 41.7 kg/m 2 . There was no difference in gastric volume between NOCARB and CARB (17.0 vs 16.1 mL, p = 0.59). The NOCARB group had lower pH values than the CARB group (2.8 vs 3.8, p = 0.001). Subset analysis of 23 patients who had measurements on both screening and intraoperative EGD revealed lower gastric volumes in CARB patients (13.3 vs 18.3, p < 0.0001). CONCLUSIONS When included in an enhanced recovery protocol, proton pump inhibitor use and preoperative carbohydrate loading 2 to 4 hours before bariatric surgery does not increase aspiration risk based on gastric volumes and pH and should be strongly considered in all eligible bariatric patients.
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Affiliation(s)
- Estella Y Huang
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Jonathan Z Li
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Daniel Chung
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Garth R Jacobsen
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Bryan J Sandler
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Anupama Wadhwa
- Department of Anesthesiology, University of Texas Southwestern, Dallas, TX (Wadhwa)
| | - Engy Said
- Department of Anesthesiology (Said, Robbins), University of California, San Diego, CA
| | - Kimberly Robbins
- Department of Anesthesiology (Said, Robbins), University of California, San Diego, CA
| | - Santiago Horgan
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
| | - Ryan C Broderick
- From the Department of Surgery, Division of Minimally Invasive Surgery (Huang, Li, Chung, Jacobsen, Sandler, Horgan, Broderick), University of California, San Diego, CA
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Burkhard JP, Jardot F, Furrer MA, Engel D, Beilstein C, Wuethrich PY. Opioid-Free Anesthesia for Open Radical Cystectomy Is Feasible and Accelerates Return of Bowel Function: A Matched Cohort Study. J Clin Med 2023; 12:jcm12113657. [PMID: 37297852 DOI: 10.3390/jcm12113657] [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: 04/10/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The aim of this study was to evaluate the feasibility of opioid-free anesthesia (OFA) in open radical cystectomy (ORC) with urinary diversion and to assess the impact on recovery of gastrointestinal function. We hypothesized that OFA would lead to earlier recovery of bowel function. A total of 44 patients who underwent standardized ORC were divided into two groups (OFA group vs. control group). In both groups, patients received epidural analgesia (OFA group: bupivacaine 0.25%, control group: bupivacaine 0.1%, fentanyl 2 mcg/mL, and epinephrine 2 mcg/mL). The primary endpoint was time to first defecation. Secondary endpoints were incidence of postoperative ileus (POI) and incidence of postoperative nausea and vomiting (PONV). The median time to first defecation was 62.5 h [45.8-80.8] in the OFA group and 118.5 h [82.6-142.3] (p < 0.001) in the control group. With regard to POI (OFA group: 1/22 patients (4.5%); control group: 2/22 (9.1%)) and PONV (OFA group: 5/22 patients (22.7%); control group: 10/22 (45.5%)), trends but no significant results were found (p = 0.99 and p = 0.203, respectively). OFA appears to be feasible in ORC and to improve postoperative functional gastrointestinal recovery by halving the time to first defecation compared with standard fentanyl-based intraoperative anesthesia.
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Affiliation(s)
- John-Patrik Burkhard
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
- Limmat Cleft- and Craniofacial Centre Zurich, 8005 Zurich, Switzerland
| | - François Jardot
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Marc A Furrer
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
- Department of Urology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Dominique Engel
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Christian Beilstein
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
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Beloborodov V, Vorobev V, Hovalyg T, Seminskiy I, Sokolova S, Lapteva E, Mankov A. Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty. Adv Urol 2023; 2023:2205306. [PMID: 37214228 PMCID: PMC10195176 DOI: 10.1155/2023/2205306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/08/2023] [Accepted: 04/09/2023] [Indexed: 05/24/2023] Open
Abstract
Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. The study aims to analyze the enhanced recovery protocol effectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. There were two groups of patients FTS-group (group II, n = 25) and standard group (group I, n = 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. The comparative intergroup efficacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p=0.004). The overall efficacy of urethroplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p=0.870), as well as the likelihood of relapse within two years (p=0.512). The predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p=0.002). The FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p < 0.001). The use of the "fast track surgery" protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.
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Affiliation(s)
- Vladimir Beloborodov
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Vladimir Vorobev
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Temirlan Hovalyg
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Igor Seminskiy
- Department of Phatology, Irkutsk State Medical University, Irkutsk, Russia
| | - Svetlana Sokolova
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Ekaterina Lapteva
- Department of Geriatrics, Propaedeutics and Management in Nursing, North-Western State Medical University Named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Aleksandr Mankov
- Department of Anesthesiology-Resuscitation, Irkutsk State Medical University, Irkutsk, Russia
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Reijnders-Boerboom GT, Albers KI, Jacobs LM, van Helden E, Rosman C, Díaz-Cambronero O, Mazzinari G, Scheffer GJ, Keijzer C, Warlé MC. Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:1400-1411. [PMID: 37026807 PMCID: PMC10389627 DOI: 10.1097/js9.0000000000000289] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 02/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group. MATERIALS AND METHODS We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay. RESULTS Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73). CONCLUSIONS Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.
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Affiliation(s)
| | - Kim I. Albers
- Departments of Anesthesiology
- Surgery, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Oscar Díaz-Cambronero
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
| | - Guido Mazzinari
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
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Kırtıl İ, Kanan N, Karip AB. Effects of a Mobilization Program Applied to Bariatric Surgery Patients on Preventing Gastrointestinal Complications: a Quasi-Experimental Study. Obes Surg 2023:10.1007/s11695-023-06609-z. [PMID: 37084024 DOI: 10.1007/s11695-023-06609-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE To investigate the effects of a planned early targeted mobilization program applied to patients that underwent bariatric surgery with the laparoscopic sleeve gastrectomy method on gastrointestinal complications (nausea-vomiting, abdominal distention, delayed flatus-defecation, and intolerance of early oral intake). MATERIALS AND METHODS This prospective, controlled group, quasi-experimental design study was conducted between July 2019 and March 2020 in the general surgery clinic of a training and research hospital with 70 patients who underwent sleeve gastrectomy and met the inclusion criteria. The prepared mobilization program was applied to the patients on the 0th, 1st, and 2nd postoperative days, and the gastrointestinal functions of the patients were monitored. RESULTS The intervention group had a significantly shorter time to first flatus, defecation, and oral intake; higher frequency of defecation; lower pain, abdominal distention, and nausea; better tolerance of oral intake; and higher total oral intake compared to the control group (p < 0.05). CONCLUSION Planned, early, and targeted mobilization was determined to be a feasible, safe, and cost-effective nursing intervention to prevent gastrointestinal complications in patients undergoing sleeve gastrectomy.
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Affiliation(s)
- İnci Kırtıl
- Department of Nursing, Faculty of Health Sciences, Yeditepe University, Istanbul, Turkey.
| | - Nevin Kanan
- Department of Nursing, Faculty of Health Sciences, Halic University, Istanbul, Turkey
| | - Aziz B Karip
- Private Practice, General Surgery, Istanbul, Turkey
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Age-related disparities and trends in national healthcare spending for management of appendicitis in the United States: A retrospective cost-analysis. Surgery 2023; 173:896-903. [PMID: 36642654 DOI: 10.1016/j.surg.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States. DESIGN The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges. RESULTS In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0-$10.8], a 2-fold increase from $4.7 billion ($4.0-$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change -3.7% [-4.4% to -2.9%]). Patients ≥65 years accounted for 64.1% (61.1%-67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy. CONCLUSION Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.
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Edwards J, Binongo J, Mullin B, Wei J, Ghelani K, Kumarasamy M, Hanson P, Duggan M, Shoffstall J, Halkos M. Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:511-517. [PMID: 35870521 DOI: 10.1016/j.athoracsur.2022.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/16/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated. METHODS A total of 215 consecutive patients underwent robotic-assisted coronary artery bypass grafting, with 156 preoperatively stratified into conventional ICU recovery vs 59 candidates for a defined ICU-bypass protocol involving recovery room and floor care. Of these, 40 candidates completed the protocol, and 19 had conversion-to-ICU recovery. Because of right-skewed distribution, inpatient cost was log-transformed, and linear regression models were constructed to estimate geometric mean ratios (GMRs) comparing inpatient cost for these groups (conventional ICU recovery, ICU-bypass, conversion-to-ICU recovery), adjusted for The Society of Thoracic Surgeons Predicted Risk of Mortality score. RESULTS Compared with the conventional ICU group, the ICU-bypass group conferred a 15% reduction in total inpatient (GMR, 0.85; P = .0007) and a 14% reduction in total variable direct costs (GMR, 0.86; P = .003). Compared with the conventional ICU group, the ICU-bypass and conversion-to-ICU groups had similar net hospital stay reductions (1.6-1.7 days). Relative to the conventional ICU group, ICU and floor duration were shortened after conversion to ICU, with a trend to reduced costs. Cardiac arrest, 30-day mortality, and stroke were absent, and other key adverse events did not differ between groups. CONCLUSIONS A selective, successful ultra-fast-track ICU-bypass protocol for robotic-assisted coronary artery bypass grafting reduces inpatient cost without affecting short-term outcomes. Conversion-to-ICU recovery also maintains outcomes and trends toward reduced costs.
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Affiliation(s)
- Joseph Edwards
- Department of Anesthesiology, Emory University, Atlanta, Georgia.
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brian Mullin
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Jane Wei
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kunali Ghelani
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Peyton Hanson
- School of Medicine, Emory University, Atlanta, Georgia
| | - Michael Duggan
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | - Michael Halkos
- Department of Surgery, Emory University, Atlanta, Georgia
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Puccetti F, Elmore U, Rosati R. Application of ERAS protocols in esophagogastric emergency surgery: is it feasible and does it make sense? Updates Surg 2023; 75:383-387. [PMID: 36044180 DOI: 10.1007/s13304-022-01362-x] [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: 03/24/2022] [Accepted: 08/13/2022] [Indexed: 01/24/2023]
Abstract
Management and treatment of esophagogastric diseases have been evolving in terms of multimodal approach and quality of care. The recent introduction of standardized perioperative protocols has represented the opportunity to homogenize the multiple factors enhancing patients' recovery after surgery worldwide. A further optimization would lead to the extension of the ERAS program to upper GI emergencies. This review provides a comprehensive collection of scientific basis, current supporting evidence, and potential applicative limitations.
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Affiliation(s)
- Francesco Puccetti
- Department of Gastrointestinal Surgery, San Raffaele Research Hospital, Via Olgettina 60, 20132, Milan (MI), Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, San Raffaele Research Hospital, Via Olgettina 60, 20132, Milan (MI), Italy.
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Research Hospital, Via Olgettina 60, 20132, Milan (MI), Italy
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Wu EB, Huang SC, Lu HI, Illias AM, Wang PM, Huang CJ, Shih TH, Chin JC, Wu SC. Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis. Br J Anaesth 2023; 130:e119-e127. [PMID: 36038393 DOI: 10.1016/j.bja.2022.07.046] [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: 11/01/2021] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). METHODS This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. RESULTS Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005). CONCLUSIONS During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.
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Affiliation(s)
- En-Bo Wu
- Department of Anaesthesiology, Kaohsiung, Taiwan
| | | | - Hung-I Lu
- Department of Thoracic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Amina M Illias
- Department of Anaesthesiology, Linko Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Pei-Ming Wang
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | | | - Jo-Chi Chin
- Department of Anaesthesiology, Park One International Hospital, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anaesthesiology, Kaohsiung, Taiwan.
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Textbook outcome in gastric surgery, what implications does it have on survival? Cir Esp 2023; 101:20-28. [PMID: 35787475 DOI: 10.1016/j.cireng.2022.06.047] [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: 06/23/2021] [Accepted: 09/25/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The textbook outcome (TO) is a multidimensional measure to assess the quality of healthcare practice. This is reflected as the "ideal" surgical result, attending to a series of indicators or established reference points that are adapted depending on the surgical disease that we want to analyze. There are few references and series published about TO, all of them very recent. OBJECTIVE We present a series of gastric surgery from the TO perspective and we analyze its impact on survival. METHOD Retrospective observational study of all gastric neoplasms operated on in our center. PERIOD January 2015-December 2020. The criteria for TO were: margins R0, >15 lymph nodes in the histological study, no Clavien-Dindo complications > IIIa, hospital stay < 21 days, no mortality or readmission in the 30 postoperative days. A comparative analysis was performed between the TO group versus the non-TO group. RESULTS 91 patients were operated on. We reached the TO in 34.1% of the patients. The variable >15 lymph nodes was the one that most affected to achieve a TO. When performing the survival analysis, we obtained that the group in which the TO was obtained had a greater survival (p < 0.008). CONCLUSION In our series, obtaining the TO has an impact on survival which 34,1% of degree of compliance.
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Hou Y, Lu J, Xie J, Zhu R, Wu M, Wang K, Zhou J, Li J. Effects of electroacupuncture on perioperative anxiety and stress response in patients undergoing surgery for gastric or colorectal cancer: Study protocol for a randomized controlled trial. Front Psychiatry 2023; 14:1095650. [PMID: 36911113 PMCID: PMC9995716 DOI: 10.3389/fpsyt.2023.1095650] [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: 11/11/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Perioperative anxiety is one of the main psychological stresses experienced by patients who undergo cancer surgery. The surgery itself inevitably causes a stress response characterized by activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. Both the perioperative anxiety and surgical stress response lead to increased levels of catecholamines and prostaglandins, which may be related to perioperative suppression of antimetastatic immunity and tumor-promoting alterations in the microenvironment. Hence, we designed this clinical trial to investigate the effect of electroacupuncture in reducing perioperative anxiety and surgical stress response. METHODS This is a randomized, single-center, parallel, and controlled clinical trial. Seventy-eight participants between the ages of 35 and 85 with gastric or colorectal cancer who plan to undergo tumorectomy will be randomly divided into an electroacupuncture group and a control group. The primary outcome will be the six-item short form of the State-Trait Anxiety Inventory score. The secondary outcomes will be the Amsterdam Preoperative Anxiety and Information Scale score; levels of plasma cortisol, adrenocorticotropic hormone, interleukin-6, and tumor necrosis factor-α; first exhaust time after surgery; postoperative quality of the recovery-15 score, numeric rating scale for pain score; and dosage of postoperative analgesics. DISCUSSION Cumulative studies revealed the efficacy of various types of acupuncture therapy with regard to reducing the anxiety and stress response caused by surgery. We expect that the results of this trial will provide high-quality clinical evidence for the choice of perioperative acupuncture for patients undergoing cancer surgery. CLINICAL TRIAL REGISTRATION https://www.chictr.org.cn, identifier ChiCTR200003 7127.
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Affiliation(s)
- Yuchao Hou
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiajing Lu
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing Xie
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Runjia Zhu
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengdie Wu
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ke Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jia Zhou
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing Li
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Loreto M, Pisanti M, Celentani M, Pasta G, Erman A, Santangelo C, Giaccari LG, Sansone P, Villani R. Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:54. [PMID: 37386677 DOI: 10.1186/s44158-022-00083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/06/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND We carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring. RESULTS Average total infusion of fluids was 1600 +/- 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo's test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II. CONCLUSIONS Hypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.
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Affiliation(s)
- Maria Loreto
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Massimo Pisanti
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Marco Celentani
- Department of Economics, Universidad Carlos III de Madrid, Madrid, Spain
| | - Gilda Pasta
- National Cancer Institute IRCCS - "G. Pascale" Foundation, Naples, Italy
| | - Alfredo Erman
- Fatebenefratelli "S. Giovanni di Dio" Hospital, Naples, Italy
| | | | | | | | - Romolo Villani
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
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Gu YJ, Chen LM, Gu ME, Xu HX, Li J, Wu LY. Body mass index-based predictions and personalized clinical strategies for colorectal cancer in the context of PPPM. EPMA J 2022; 13:615-632. [PMID: 36505896 PMCID: PMC9727065 DOI: 10.1007/s13167-022-00306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
Currently colorectal cancer (CRC) is the third most prevalent cancer worldwide. Body mass index (BMI) is frequently used in CRC screening and risk assessment to quantitatively evaluate weight. However, the impact of BMI on clinical strategies for CRC has received little attention. Within the framework of the predictive, preventive, and personalized medicine (3PM/PPPM), we hypothesized that BMI stratification would affect the primary, secondary, and tertiary care options for CRC and we conducted a critical evidence-based review. BMI dynamically influences CRC outcomes, which helps avoiding adverse treatment effects. The outcome of surgical and radiation treatment is adversely affected by overweight (BMI ≥ 30) or underweight (BMI < 20). A number of interventions, such as enhanced recovery after surgery and robotic surgery, can be applied to CRC at all levels of BMI. BMI-controlling modalities such as exercise, diet control, nutritional therapy, and medications may be potentially beneficial for patients with CRC. Patients with overweight are advised to lose weight through diet, medication, and physical activity while patients suffering of underweight require more focus on nutrition. BMI assists patients with CRC in better managing their weight, which decreases the incidence of adverse prognostic events during treatment. BMI is accessible, noninvasive, and highly predictive of clinical outcomes in CRC. The cost-benefit of the PPPM paradigm in developing countries can be advanced, and the clinical benefit for patients can be improved with the promotion of BMI-based clinical strategy models for CRC.
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Affiliation(s)
- Yun-Jia Gu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China ,grid.412540.60000 0001 2372 7462Shanghai Qigong Research Institute, Shanghai University of Traditional Chinese Medicine, No. 650 South Wanping Road, Shanghai, 200030 China
| | - Li-Ming Chen
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Mu-En Gu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Hong-Xiao Xu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Jing Li
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Lu-Yi Wu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
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Lu J, Khamar J, McKechnie T, Lee Y, Amin N, Hong D, Eskicioglu C. Preoperative carbohydrate loading before colorectal surgery: a systematic review and meta-analysis of randomized controlled trials. Int J Colorectal Dis 2022; 37:2431-2450. [PMID: 36472671 DOI: 10.1007/s00384-022-04288-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Preoperative carbohydrate loading has been introduced as a component of many enhanced recovery after surgery programs. Evaluation of current evidence for preoperative carbohydrate loading in colorectal surgery has never been synthesized. METHODS MEDLINE, Embase, and CENTRAL were searched until May 2021. Randomized controlled trials (RCTs) comparing patients undergoing colorectal surgery with and without preoperative carbohydrate loading were included. Primary outcomes were changes in blood insulin and glucose levels. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS The search yielded 3656 citations, from which 12 RCTs were included. In total, 387 patients given preoperative carbohydrate loading (47.2% female, age: 62.0 years) and 371 patients in control groups (49.4% female, age: 61.1 years) were included. There was no statistical difference for blood glucose and insulin levels between both patient groups. Patients receiving preoperative carbohydrate loading experienced a shorter time to first flatus (SMD: - 0.48 days, 95% CI: - 0.84 to - 0.12, p = 0.008) and stool (SMD: - 0.50 days, 95% CI: - 0.86 to - 0.14, p = 0.007). Additionally, length of stay was shorter in the preoperative carbohydrate loading group (SMD: - 0.51 days, 95% CI: - 0.88 to - 0.14, p = 0.007). There was no difference in postoperative morbidity and patient well-being between both groups. CONCLUSIONS Preoperative carbohydrate loading does not significantly impact postoperative glycemic control in patients undergoing colorectal surgery; however, it may be associated with a shorter length of stay and faster return of bowel function. It merits consideration for inclusion within colorectal enhanced recovery after surgery protocols.
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Affiliation(s)
- Justin Lu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
| | - Nalin Amin
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada.
- Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Dantes G, Keane OA, Margol M, Thompson O, Darville G, Clifton MS, Heiss KF. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic cholecystectomy surgery. Pediatr Surg Int 2022; 38:1517-1523. [PMID: 36069916 DOI: 10.1007/s00383-022-05195-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Enhanced recovery protocols [ERPs] standardize care and have been demonstrated to improve surgical quality in adults. We retrospectively compared outcomes before and after implementation of ERPs in children undergoing elective laparoscopic cholecystectomy [ELC] surgery. METHODS A pediatric-specific ERP was implemented for children undergoing ELC at one [C1] of the two Pediatric Surgical Centers in July 2016. We retrospectively reviewed 606 patients undergoing ELC between July 2014 and December 2019. Of these, 206 patients underwent ELC prior to ERP implementation [Pre-ERP] were compared to 400 patients undergoing ELC managed in the post-ERP implementation period (between January 2017 and December 2019), 21 of which were managed by enhanced recovery protocol. Primary Outcomes included immediate peri-operative and post-operative narcotic use in mean morphine equivalents [MME], narcotics at discharge, complications, nurse calls and returns to system [RTS]. RESULTS There was a significant decrease in opioid use both post-operatively and at time of discharge in the ERP managed cohort. The MME use during the post-operative period was 0.85 in the in ERP-compliant patients compared to 6.40 in the non-compliant group (p < 0.027). Eighty-six percent of ERP-compliant patients in the study required no narcotics at discharge, which was statistically significant when compared to ERP non-compliant cohort (p < 0.0001). There was also no change in RTS, nurse calls or complications. In addition, in the post-ERP period (2017-2019), a dominant proportion of patients at C1 partially complied with the ERP, resulting in a statistically significantly decrease of opioid use between sites in the post-op period (6.54 vs 10.57 MME) post-ERP (p < 0.001). Similar effects were noted in discharge narcotics. CONCLUSION The use of pediatric-specific ERP in children undergoing ELC is safe, effective, and provides compassionate pain control while leading to a reduction in opioid use peri-operatively and at discharge. This improvement occurred without changes in RTS, nursing calls or complications. LEVEL OF EVIDENCE Level III; Retrospective study.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Olivia A Keane
- Department of Pediatrics, Children's Healthcare of Atlanta, GI Care for Kids, Atlanta, GA, USA
| | - Matthew Margol
- Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Gregory Darville
- Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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