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Zhang P, Dang X, Li X, Liu B, Wang Q. Enhanced recovery after surgery in percutaneous transhepatic cholangioscopic lithotripsy for patients with hepatolithiasis and choledocholithiasis. Surg Open Sci 2024; 20:38-44. [PMID: 38911053 PMCID: PMC11190742 DOI: 10.1016/j.sopen.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/05/2024] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Background Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) provides an effective alternative procedure for the management of complex hepatolithiasis and choledocholithiasis. Enhanced recovery after surgery (ERAS) program is an evidence-based approach that was developed to reduce surgical stress and accelerate postoperative recovery. However, little is known regarding PTCSL in the context of ERAS. The aim of this study was to evaluate the efficacy and safety of PTCSL within ERAS programs. Patient and methods The clinical data of patients who underwent PTCSL within ERAS programs consulted at our hospital between November 2017 and November 2022 was retrospectively reviewed. Individualized perioperative ERAS items were evaluated for all patients. The demographics, intraoperative variables, and postoperative outcomes were analyzed. Results A total of 43 patients who underwent PTCSL were included in the study. There were 13 men and 30 women aged between 39 and 89 years with an average age of 60 years (60.49 ± 12.37). The stone clearance rate was 77 % after the first operation, and the final clearance rate was 95 %. The incidence of complications in this study is 18.6 % (8/43), including 6 patients with Clavien-Dindo I-II, and 2 patients with Clavien-Dindo III. Pleural effusion, abdominal effusion, infection, bile leakage, and biliary bleeding are the most common complications, however, all patients recovered after aggressive treatment. Conclusion PTCSL is a relatively safe, feasible, and efficient method for treating complex hepatolithiasis and choledocholithiasis within ERAS programs. Individualized ERAS entries and precise disease management are required to minimize the occurrence of complications and to provide effective treatment.
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Affiliation(s)
- Peng Zhang
- Department of General Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xi Dang
- Department of General Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaojie Li
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bo Liu
- Department of General Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Qingliang Wang
- Department of General Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Mavroeidis VK, Knapton J, Saffioti F, Morganstein DL. Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team. World J Diabetes 2024; 15:598-605. [PMID: 38680702 PMCID: PMC11045411 DOI: 10.4239/wjd.v15.i4.598] [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: 12/30/2023] [Revised: 01/30/2024] [Accepted: 03/01/2024] [Indexed: 04/11/2024] Open
Abstract
Pancreatic surgery units undertake several complex operations, albeit with considerable morbidity and mortality, as is the case for the management of complicated acute pancreatitis or chronic pancreatitis. The centralisation of pancreatic surgery services, with the development of designated large-volume centres, has contributed to significantly improved outcomes. In this editorial, we discuss the complex associations between diabetes mellitus (DM) and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis, highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services. Type 3c pancreatogenic DM, refers to DM developing in the setting of exocrine pancreatic disease, and its identification and management can be challenging, while the glycaemic control of such patients may affect their course of treatment and outcome. Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period. The incidence of new onset diabetes after pancreatic resection is widely variable in the literature, and depends on the type and extent of pancreatic resection, as is the case with pancreatic parenchymal loss in the context of severe pancreatitis. Early involvement of a specialist diabetes team is essential to ensure a holistic management. In the current era, large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery, with inclusion of provisions for optimisation of the perioperative glycaemic control, to improve outcomes. While various guidelines are available to aid perioperative management of DM, auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement. The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined, a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis. Therefore, pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams. With the ongoing accumulation of evidence, it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.
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Affiliation(s)
- Vasileios K Mavroeidis
- Department of HPB Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, United Kingdom
- Department of Gastrointestinal Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Jennifer Knapton
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
- UCL Institute for Liver and Digestive Health, University College London, London NW3 2PF, United Kingdom
| | - Daniel L Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, United Kingdom
- Department of Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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He MM, Zhou ZF, Yu XF, Zhou CC. Effect of RARC-ERAS nursing program on clinical outcomes in patients undergoing RARC surgery: a retrospective, propensity matching study. J Robot Surg 2024; 18:170. [PMID: 38598030 PMCID: PMC11006731 DOI: 10.1007/s11701-024-01931-9] [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: 02/25/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
Currently, there is no specific perioperative nursing standard for RARC based on the ERAS concept. This retrospective study investigates to analyze the effect of RARC-ERAS nursing program on VTE and other clinical outcomes in patients undergoing RARC surgery. This retrospective study included 216 patients undergoing RARC surgery From January 1, 2022 to December 30, 2023, and propensity score adjustment analysis was applied. The study compares a control group receiving traditional nursing and an observation group receiving RARC-ERAS nursing program. Perioperative variables and other postoperative complications were retrieved from the hospital medical records. After propensity score matching, there were no significant differences in the demographic and clinical characteristics between the two groups (p > 0.05). The ERAS group exhibited aa significantly higher rate of postoperative unobstructed venous blood flow in the lower extremities by color Doppler ultrasound as compared to the control group (94.6% VS 80.4%, p = 0.042). Before anesthesia induction, lower preoperative anxiety and surgical information needs scores were observed in the ERAS group than in the control group (p < 0.05). Compared to the control group, the ERAS group demonstrated a shorter surgical duration, a lower incidence of perioperative hypothermia, less time needed for getting out of bed, anal exhaust, and for defecation after returning to the ward (p < 0.05). RARC-ERAS nursing program significantly increased the rate of postoperative unobstructed venous blood flow in the lower extremities by color doppler ultrasound, lower preoperative anxiety and intraoperative hypothermia in patients undergoing RARC. This nursing approach presents a valuable strategy for enhancing patient outcomes and merits further exploration in clinical practice.Trial registration:ChiCTR2400081118; http://www.chictr.org.cn , Principal investigator: Mang-mang He, Date of registration: Feb 22, 2024.
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Affiliation(s)
- Mang-Mang He
- Department of the Operating Room, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 315000, Zhejiang, China
| | - Zhen-Feng Zhou
- Department of Anesthesiology, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital, Hangzhou First People's Hospital Qianjiang New City Campus, Zhejiang Chinese Medical University), Hangzhou, 310008, China
| | - Xiao-Fen Yu
- Department of the Operating Room, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 315000, Zhejiang, China
| | - Chun-Cong Zhou
- Department of Urolithiasis and Anorectal Surgery, Ningbo No. 2 Hospital, 41 Xibei Street, Ningbo, 315010, Zhejiang, China.
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Rao SJ, Solsky I, Gunawan A, Shen P, Levine E, Clark CJ. Phase 1 randomized trial of inpatient high-intensity interval training after major surgery. J Gastrointest Surg 2024; 28:528-533. [PMID: 38583906 DOI: 10.1016/j.gassur.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/03/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND High-intensity interval training (HIT) can provide physiologic benefits and may improve postoperative recovery but has not been evaluated in inpatients. This study aimed to evaluate the safety and tolerability of HIT after major surgery. METHODS We performed a phase I randomized study comparing HIT with low-intensity continuous ambulation (40 m) during the initial inpatient stay after major surgery at a large academic center. Clinicopathologic and pre- and post-exercise physiologic data were captured. Perceived exertion was measured throughout the intervention. RESULTS Twenty-two subjects were enrolled and randomized with 90% (20 subjects, 10 per arm) completing all aspects of the study. One patient declined participation in the exercise intervention. The HIT and continuous ambulation groups were relatively similar in terms of median age (65.5 vs 63.5), female sex (20% vs 40%), White race (90% vs 90%), having a cancer diagnosis (100% vs 80%), undergoing gastrointestinal surgery (60% vs 80%), median Karnofsky score (60 vs 60), and ability to independently ambulate preoperatively (100% vs 90%). All subjects completed the exercise without protocol deviation, cohort crossover, or safety events. Compared with the continuous ambulation group, the HIT group had higher end median perceived exertion (5.0 [IQR, 5.5] vs 3.0 [IQR, 1.8]), shorter overall time to complete assigned exercise (56.6 seconds vs 91.8 seconds), and a trend toward higher median gait speed over 40 m (0.71 m/s vs 0.44 m/s, P = .126). CONCLUSION HIT in the hospitalized postoperative patient is safe and may be implemented to help promote positive physiologic outcomes and recovery.
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Affiliation(s)
- Shambavi J Rao
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Ian Solsky
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Antonius Gunawan
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Perry Shen
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Edward Levine
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Clancy J Clark
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States.
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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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Mulliri A, Joubert M, Piquet MA, Alves A, Dupont B. Functional sequelae after pancreatic resection for cancer. J Visc Surg 2023; 160:427-443. [PMID: 37783613 DOI: 10.1016/j.jviscsurg.2023.09.002] [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: 10/04/2023]
Abstract
The morbidity and mortality of pancreatic cancer surgery has seen substantial improvement due to the standardization of surgical techniques, the optimization of perioperative multidisciplinary management and the organization of specialized care systems. The identification and treatment of postoperative functional and nutritional sequelae have thereby become major issues in patients who undergo pancreatic surgery. This review addresses the functional sequelae of pancreatic resection for cancerous and pre-cancerous lesions (excluding chronic pancreatitis). Its aim is to specify the prevalence and severity of sequelae according to the type of pancreatic resection and to document, where appropriate, the therapeutic management. Exocrine pancreatic insufficiency (ExPI) is observed in nearly one out of three patients at one year after surgery, and endocrine pancreatic insufficiency (EnPI) is present in one out of five patients after pancreatoduodenectomy (PD) and one out of three patients after distal pancreatectomy (DP). In addition, digestive functional disorders may appear, such as delayed gastric emptying (DGE), which affects 10 to 45% of patients after PD and nearly 8% after DP. Beyond these functional sequelae, pancreatic surgery can also induce nutritional and vitamin deficiencies secondary to a lack of uptake for certain vitamins or to the loss of absorption site in the duodenum. In addition to the treatment of ExPI with oral pancreatic enzymes, nutritional management is based on a high-calorie, high-protein diet with normal lipid intake in frequent small feedings, combined with vitamin supplementation adapted to monitored deficiencies. Better knowledge of the functional consequences of pancreatic cancer surgery can improve the overall management of patients.
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Affiliation(s)
- Andrea Mulliri
- Digestive Surgery Department, University Hospital Center of Caen, Normandie Université, UNICAEN, 14000 Caen, France; Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France
| | - Michael Joubert
- Diabetology-Endocrinology Department, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France
| | - Marie-Astrid Piquet
- Department of Hepato-Gastroenterology and Nutrition, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France
| | - Arnaud Alves
- Digestive Surgery Department, University Hospital Center of Caen, Normandie Université, UNICAEN, 14000 Caen, France; Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France
| | - Benoît Dupont
- Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France; Department of Hepato-Gastroenterology and Nutrition, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France.
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Chaudhari V, Ramaswamy A, Srinivas S, Agarwal A, Seshadri RA, Talwar V, Bhargava P, Goel S, Kayal S, Rebala P, Prajapati B, Parikh D, Kothari J, Ch RM, Kadamapuzha JM, Kapoor D, Chaudhary A, Goel V, Singh S, Ghosh J, Lavingia V, Gupta A, Sekar A, Misra S, Vishnoi JR, Soni S, Varshney VK, Bairwa S, Bhandare M, Shrikhande SV, Ostwal V. Practice Patterns and Survival in Patients with Resected Pancreatic Ductal Adenocarcinomas (PDAC) - Results from the Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) Study. J Gastrointest Cancer 2023; 54:1338-1346. [PMID: 37273074 DOI: 10.1007/s12029-023-00936-1] [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] [Accepted: 04/03/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND There is limited data from India with regard to presentation, practice patterns and survivals in resected pancreatic ductal adenocarcinomas (PDACs). METHODS The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) included data from 8 major academic institutions across India and presents the outcomes in upfront resected PDACs from January 2015 to June 2019. RESULTS Of 288 patients, R0 resection was achieved in 81% and adjuvant therapy was administered in 75% of patients. With a median follow-up of 42 months (95% CI: 39-45), median DFS for the entire cohort was 39 months (95% CI: 25.4-52.5), and median overall survival (OS) was 45 months (95% CI: 32.3-57.7). A separate analysis was done in which patients were divided into 3 groups: (a) those with stage I and absent PNI (SI&PNI-), (b) those with either stage II/III OR presence of PNI (SII/III/PNI+), and (c) those with stage II/III AND presence of PNI (SII/III&PNI+). The DFS was significantly lesser in patients with SII/III&PNI+ (median 25, 95% CI: 14.1-35.9 months), compared to SII/III/PNI + (median 40, 95% CI: 24-55 months) and SI&PNI- (median, not reached) (p = 0.036)). CONCLUSIONS The MIPPAP study shows that resectable PDACs in India have survivals at par with previously published data. Adjuvant therapy was administered in 75% patients. Adjuvant radiotherapy does not seem to add to survival after R0 resection.
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Affiliation(s)
- Vikram Chaudhari
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Anant Ramaswamy
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sujay Srinivas
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Ajit Agarwal
- Balco Medical Centre Raipur India, Uparwara, Raipur, India
| | | | - Vineet Talwar
- Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | - Prabhat Bhargava
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Shaifali Goel
- Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | - Smita Kayal
- Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | | | | | | | | | - Ramesh M Ch
- Lakeshore Hospital & Research Center, Kochi, Kerala, India
| | | | | | | | - Varun Goel
- Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | - Shivendra Singh
- Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | | | | | - Amit Gupta
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Anbarasan Sekar
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sanjeev Misra
- All India Institute of Medical Sciences, Jodhpur, India
| | | | - Subhash Soni
- All India Institute of Medical Sciences, Jodhpur, India
| | | | | | - Manish Bhandare
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | | | - Vikas Ostwal
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India.
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Karunakaran M, Roulin D, Ullah S, Shrikhande SV, De Boer HD, Demartines N, Barreto SG. Global Perceptions on ERAS ® in Pancreatoduodenectomy. World J Surg 2023; 47:2977-2989. [PMID: 37787776 PMCID: PMC10694106 DOI: 10.1007/s00268-023-07198-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Uptake of ERAS® pathways for pancreatic surgery have been slow and impacted by low compliance. OBJECTIVE To explore global awareness, perceptions and practice of ERAS® peri-pancreatoduodenectomy (PD). METHODS A structured, web-based survey (EPSILON) was administered through the ERAS® society and IHPBA membership. RESULTS The 140 respondents included predominantly males (86.4%), from Europe (45%), practicing surgery (95%) at academic/teaching hospitals (63.6%) over a period of 10-20 years (38.6%). Most respondents identified themselves as general surgeons (68.6%) with 40.7% reporting an annual PD volume of 20-50 cases, practicing post-PD clinical pathways (37.9%), with 31.4% of respondents auditing their outcomes annually. Reduced medical complications, cost and hospital length of stay, and improved patient satisfaction were perceived benefits of compliance to enhancing-recovery. Multidisciplinary co-ordination was considered the most important factor in the implementation and sustainability of peri-PD ERAS® pathways, while reluctance to change among health care practitioners, difficulties in data collection and audit, lack of administrative support, and recruitment of an ERAS® dedicated nurse were reported to be important barriers. CONCLUSIONS The EPSILON survey highlighted global clinician perceptions regarding the benefits of compliance to peri-PD ERAS®, the importance of individual components, perceived facilitators and barriers, to the implementation and sustainability of these pathways.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, 500 032, India
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV and University of Lausanne UNIL, 1011, Lausanne, Switzerland
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Training School Complex, Anushakti Nagar, Mumbai, 400085, India
| | - Hans D De Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV and University of Lausanne UNIL, 1011, Lausanne, Switzerland.
| | - Savio George Barreto
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, 500 032, India.
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, 5042, Australia.
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9
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Grabar C, Fligor J, Kanack M, Walsh J, Kim J, Vyas R. A Survey on Enhanced Recovery After Surgery (ERAS) Elements in Cleft Palate Repair. Cleft Palate Craniofac J 2023; 60:1305-1312. [PMID: 35619553 DOI: 10.1177/10556656221103756] [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: 11/16/2022] Open
Abstract
This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons. Craniofacial surgeons were provided with electronic surveys. Electronic survey; Institutional tertiary surgeons. 102 cleft palate surgeons surveyed and 31 completed the survey (30.4%). None. Respondents rated their knowledge, use, and willingness to implement perioperative interventions modeled after adult ERAS protocols. Majority (67.7%) rated they were knowledgeable about ERAS. However, 61.3% "never use" a standardized protocol for cleft palate surgery. Only 3 ERAS elements are currently implemented by a majority of cleft surgeons: avoiding prolonged perioperative fasting (67.7%), using hypothermia prevention measures (74.2%), and minimizing use of opioids (62.5%). A large majority of respondents noted they never administer bolus (71.0%) or infusion (80.6%) dosing of tranexamic acid; most of these surgeons also indicated that administering tranexamic acid "would not be a valuable addition" (67.7% and 71.0%, respectively). Short-acting sedatives are used by 12.9% and by 16.1% of surgeons in all patients during extubation and postoperative recovery, respectively. By contrast, 22.6% never use such agents during extubation and 48.4% never use it during postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repair. Many respondents report using interventions compatible with an ERAS approach and the majority are willing to implement an ERAS protocol for cleft palate repair.
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Affiliation(s)
- Christina Grabar
- School of Medicine, University of California Irvine, Orange, CA, USA
| | - Jennifer Fligor
- Department of Plastic Surgery, University of California Irvine, Orange, CA, USA
| | - Melissa Kanack
- Department of Plastic Surgery, University of California Irvine, Orange, CA, USA
| | - Juleah Walsh
- Pediatric Plastic Surgery, CHOC Children's, Orange, CA, USA
| | - Joe Kim
- Pediatric Plastic Surgery, CHOC Children's, Orange, CA, USA
| | - Raj Vyas
- Department of Plastic Surgery, University of California Irvine, Orange, CA, USA
- Pediatric Plastic Surgery, CHOC Children's, Orange, CA, USA
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Pagano L, Hemmert C, Hirschhorn A, Francis-Auton E, Arnolda G, Long JC, Braithwaite J, Gumley G, Hibbert PD, Churruca K, Hutchinson K, Partington A, Hughes C, Gillatt D, Ellis LA, Testa L, Patel R, Sarkies MN. Implementation of consensus-based perioperative care pathways to reduce clinical variation for elective surgery in an Australian private hospital: a mixed-methods pre-post study protocol. BMJ Open 2023; 13:e075008. [PMID: 37495386 PMCID: PMC10373689 DOI: 10.1136/bmjopen-2023-075008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION Addressing clinical variation in elective surgery is challenging. A key issue is how to gain consensus between largely autonomous clinicians. Understanding how the consensus process works to develop and implement perioperative pathways and the impact of these pathways on reducing clinical variation can provide important insights into the effectiveness of the consensus process. The primary objective of this study is to understand the implementation of an organisationally supported, consensus approach to implement perioperative care pathways in a private healthcare facility and to determine its impact. METHODS A mixed-methods Effectiveness-Implementation Hybrid (type III) pre-post study will be conducted in one Australian private hospital. Five new consensus-based perioperative care pathways will be developed and implemented for specific patient cohorts: spinal surgery, radical prostatectomy, cardiac surgery, bariatric surgery and total hip and knee replacement. The individual components of these pathways will be confirmed as part of a consensus-building approach and will follow a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment framework. The process of implementation, as well as barriers and facilitators, will be evaluated through semistructured interviews and focus groups with key clinical and non-clinical staff, and participant observation. We anticipate completing 30 interviews and 15-20 meeting observations. Administrative and clinical end-points for at least 152 participants will be analysed to assess the effectiveness of the pathways. ETHICS AND DISSEMINATION This study received ethical approval from Macquarie University Human Research Ethics Medical Sciences Committee (Reference No: 520221219542374). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and reports for key stakeholders.
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Affiliation(s)
- Lisa Pagano
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Cameron Hemmert
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Hirschhorn
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Graham Gumley
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Partington
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Cliff Hughes
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Gillatt
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Luke Testa
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Romika Patel
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mitchell N Sarkies
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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11
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Noba L, Rodgers S, Doi L, Chandler C, Hariharan D, Yip V. Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis. J Cancer Res Clin Oncol 2023:10.1007/s00432-022-04508-x. [PMID: 36629919 PMCID: PMC10356629 DOI: 10.1007/s00432-022-04508-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: 11/04/2022] [Accepted: 11/30/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy. METHODS A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance. RESULTS The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05). CONCLUSION This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.
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Affiliation(s)
- Lyrics Noba
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK.
| | - Sheila Rodgers
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Lawrence Doi
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Colin Chandler
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Deepak Hariharan
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR, UK
| | - Vincent Yip
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR, UK
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12
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Negrini D, Graaf J, Ihsan M, Gabriela Correia A, Freitas K, Bravo JA, Linhares T, Barone P. The clinical impact of the systolic volume variation guided intraoperative fluid administration regimen on surgical outcomes after pancreaticoduodenectomy: a retrospective cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:729-735. [PMID: 35809679 PMCID: PMC9659986 DOI: 10.1016/j.bjane.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is associated with high morbidity. Many preoperative variables are risk factors for postoperative complications, but they are primarily non-modifiable. It is not clear whether an intraoperative goal-directed fluid regimen might be associated with fewer postoperative surgical complications compared to current conservative, non-goal-directed fluid practices. We hypothesize that the use of Systolic Volume Variation (SVV)-guided intraoperative fluid administration might be beneficial. METHODS Data from 223 patients who underwent pancreaticoduodenectomy in our institution between 2015 and 2019 were reviewed. Patients were classified into two groups based on the use of intraoperative use of SVV to guide the administration of fluids. The decision to use SVV or not was made by the attending anesthesiologist. Subjects were classified into SVV-guided intraoperative fluid therapy (SVV group) and non-SVV-guided intraoperative fluid therapy (non-SVV group). Uni and multivariate regression analyses were conducted to determine if SVV-guided fluid therapy was significantly associated with a lower incidence of postoperative surgical complications, such as Postoperative Pancreatic Fistula (POPF), Delayed Gastric Emptying (DGE), among others, after adjusting for confounders. RESULTS Baseline, demographic, and intraoperative characteristics were similar between SVV and non-SVV groups. In the multivariate analysis, the use of SVV guidance was significantly associated with fewer postoperative surgical complications (OR = 0.48; 95% CI 0.25-0.91; p = 0.025), even after adjusting for significant covariates, such as perioperative use of epidural, pancreatic gland parenchyma texture, and diameter of the pancreatic duct. CONCLUSIONS VV-guided intraoperative fluid administration might be associated with fewer postoperative surgical complications after pancreaticoduodenectomy.
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Affiliation(s)
- Daniel Negrini
- Universidade Federal do Estado do Rio de Janeiro, Departamento de Anestesiologia, Rio de Janeiro, RJ, Brazil; Faculdade de Medicina da Fundação Universitária Serra dos Órgãos, Teresopolis, RJ, Brazil.
| | - Jacqueline Graaf
- Faculdade de Medicina da Fundação Universitária Serra dos Órgãos, Teresopolis, RJ, Brazil
| | - Mayan Ihsan
- Medical City Teaching Hospitals, Department of Anesthesiology, Iraq
| | | | - Karine Freitas
- Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Rio de Janeiro, RJ, Brazil
| | - Jorge Andre Bravo
- Faculdade de Medicina da Fundação Universitária Serra dos Órgãos, Teresopolis, RJ, Brazil; Instituto Nacional do Câncer, Departamento de Medicina Interna, Rio de Janeiro, RJ, Brazil
| | - Tatiana Linhares
- Unimed Barra Hospital, Departamento de Medicina Interna, Rio de Janeiro, RJ, Brazil
| | - Patrick Barone
- Universidade Federal do Rio Grande do Sul, Departamento de Anestesiologia,Porto Alegre, RS, Brazil
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13
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Negrini D, Ihsan M, Freitas K, Pollazzon C, Graaf J, Andre J, Linhares T, Brandao V, Silva G, Fiorelli R, Barone P. The clinical impact of the perioperative epidural anesthesia on surgical outcomes after pancreaticoduodenectomy: A retrospective cohort study. Surg Open Sci 2022; 10:91-96. [PMID: 36062076 PMCID: PMC9436794 DOI: 10.1016/j.sopen.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/30/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022] Open
Abstract
Background Pancreaticoduodenectomy is a highly invasive procedure associated with high morbidity. Several preoperative variables are associated with postoperative complications. The role of perioperative factors is uncertain. The use of perioperative epidural analgesia is potentially associated with fewer postoperative surgical complications. We hypothesize that perioperative epidural analgesia might be associated with fewer surgical complications. Methods We reviewed data from 288 cases performed at our institution between 2012 and 2019, classifying patients into 2 groups: perioperative use of epidural analgesia and non-perioperative use of epidural analgesia. The decision to use epidural as an adjunct to general anesthesia was based on the judgment of the attending anesthesiologist. Uni- and multivariate analyses were then performed to determine factors associated with postoperative surgical complications, ie, postoperative pancreatic fistula, delayed gastric emptying, among others, after adjusting for confounders. Results Baseline and intraoperative factors were similar between the groups, except for sex and postoperative surgical complications. In the univariate analyses, factors associated with fewer postoperative surgical complications were the diameter of the pancreatic duct ≥ 6 mm, hard pancreatic gland parenchyma texture, younger age (< 65 years), and perioperative use of epidural analgesia. In the multivariate analyses, perioperative use of epidural analgesia was significantly associated with fewer postoperative surgical complications (odds ratio = 0.31; 95% confidence interval: 0.13–0.75; P = .009), even after adjusting for significant covariates. Conclusion Perioperative use of epidural analgesia might be associated with fewer postoperative surgical complications after pancreaticoduodenectomy even after adjusting for pancreatic gland parenchyma texture, pancreatic duct size, and age.
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14
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Li T, Zhang J, Zeng J, Sun M, Li D, Yuan T, Zhang R, Jiang H. Early drain removal and late drain removal in patients after pancreatoduodenectomy: A systematic review and meta-analysis. Asian J Surg 2022; 46:1909-1916. [PMID: 36207205 DOI: 10.1016/j.asjsur.2022.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
Whether early or late drain removal (EDR/LDR) is better for patients after pancreatic resection remains controversial. We aim to systematically evaluate the safety and efficacy of early or late drain removal in patients who undergo pancreatic resection. We searched seven databases from January 1, 2000, through September 2021, and included randomized controlled trials (RCTs) or observational studies comparing EDR vs. LDR in patients after pancreatic resection. We separately pooled effect estimates across RCTs and observational studies. Finally, we included 4 RCTs with 711 patients and 8 nonRCTs with 7207 patients. Based on the pooled RCT data, compared to LDR, EDR reduced hospital length of stay (LOS) (RR: -2.59, 95% CI: -4.13 to -1.06) and hospital cost (RR: -1022.27, 95% CI: -1990.39 to -54.19). Based on the pooled nonRCT data, EDR may reduce the incidence of all complications (OR: 0.45, 95% CI: 0.32 to 0.63), pancreatic fistula (OR: 0.26, 95% CI: 0.15 to 0.45), wound infection (RR: 0.59, 95% CI: 0.06 to 5.45)), reoperation (OR: 0.62, 95% CI: 0.40 to 0.96) and hospital readmission (OR: 0.57, 95% CI: 0.47 to 0.69). There was an uncertain effect on mortality (OR from pooled nonRCTs: 1.02, 95% CI: 0.41 to 2.53) and delayed gastric emptying (RR from pooled RCTs: 0.76, 95% CI: 0.41 to 1.41). The findings of this meta-analysis suggest that early drain removal is associated with lower hospital cost, is safe and may reduce the incidence of complications compared to late drain removal in patients after pancreaticoduodenectomy.
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15
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Ciprani D, Bannone E, Marchegiani G, Nessi C, Salvia R, Bassi C. Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase. Pancreatology 2022; 22:817-822. [PMID: 35773177 DOI: 10.1016/j.pan.2022.06.257] [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: 03/22/2022] [Revised: 05/22/2022] [Accepted: 06/19/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP. METHODS Patients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups. RESULTS Patients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression. CONCLUSIONS Purulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.
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Affiliation(s)
- D Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - E Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Nessi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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16
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Cho ES, Zenilman ME, McClelland PH, Rodriguez D, Steele J, Fahoum B, Wayne M. Blueprint For Safe Transition From a Low- to High-Volume Pancreatic Surgery Center. Surg Open Sci 2022; 10:156-157. [PMID: 36248182 PMCID: PMC9558100 DOI: 10.1016/j.sopen.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022] Open
Abstract
We describe a straightforward model to implement a high volume specialty surgery program at a community hospital. Using pancreatic surgery as an example, we employed published processes in three arenas. First, mandatory multidisciplinary tumor board presentations captured all the patients considered for surgery. Then, perioperative protocols using tools such as enhanced recovery and teamwork in the perioperative arena created a reproducible and safe environment for complex surgery. We critically reviewed all complications using the Clavien-Dindo methodology, and confirmed our favorable outcomes via the targeted NSQIP program. These standard steps can be used for implementation of a new complex surgical procedure.
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Affiliation(s)
| | - Michael E. Zenilman
- Corresponding author at: Department of Surgery, NewYork-Presbyterian Brooklyn Methodist Hospital, 506 6 St, Brooklyn, NY, 11215. Tel.: + 1 (718) 780-5990; fax + 1 (718) 780-7186.
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17
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Siegel JB, O'Leary R, DeChamplain B, Lancaster WP. The Effect of Goal-Directed Fluid Administration on Outcomes After Pancreatic Surgery. World J Surg 2022; 46:2760-2768. [PMID: 35896759 DOI: 10.1007/s00268-022-06676-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND We evaluated the effect of an Enhanced Recovery After Surgery protocol on intraoperative fluid administration and postoperative outcomes in pancreatic surgery. METHODS Pancreatic cancer resections at our institution from 2012 to 2018 were grouped according to pre- or post-protocol initiation. Preoperative characteristics and postoperative outcomes were compared with Fisher's exact test and chi-square for categorical variables, and Mann-Whitney U test for continuous variables. Further analysis separated patients that had a Whipple from those who had distal pancreatectomy. RESULTS A total of 263 patients underwent pancreatic cancer resection during the study period (169 Whipples, 84 DPs, 92 pre-ERAS and 171 post-ERAS). Intraoperative fluid administration significantly decreased after protocol implementation (mean 6,277 ml vs. 3870 ml, p < 0.001). This held true when separating patients that had a Whipple procedure from those that had a DP (6,929 ml vs. 4,513 ml, p < 0.001, 5,060 ml vs. 2,833 cc, p = 0.002, respectively). Intensive care unit (ICU) admission (41.3% vs. 20.5%, p < 0.001) and length of stay (9.4 vs. 8.1 days, p < 0.01) were significantly reduced after ERAS implementation for all patients and in Whipple patients alone (47.5% vs. 23.6%, p = 0.002 and 10.7 vs. 6.6 days, p = 0.004). DP patients also had significantly decreased ICU admissions (41.3% vs. 20.5%, p = 0.045). All other postoperative outcomes were not significantly different. CONCLUSION For patients undergoing pancreatic cancer resection, goal-directed fluid management is associated with decreased intraoperative fluid administration, decreased ICU admission, and decreased length of stay without an increase in postoperative complications or readmission.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
| | - Ryan O'Leary
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Bryce DeChamplain
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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18
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O'Brien SJ, Bhutiani N, Young JI, Phillips P, Weaver KH, Kline D, Vitale GC. Impact of myopenia and myosteatosis in patients undergoing abdominal surgery for chronic pancreatitis. Surgery 2022; 172:310-318. [PMID: 35246331 DOI: 10.1016/j.surg.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/09/2022] [Accepted: 01/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgery for chronic pancreatitis is associated with major morbidity and mortality. The aim of this study is to examine the role of preoperative muscle volume and quality on postoperative outcomes in patients with chronic pancreatitis. METHODS All patients who underwent abdominal surgery for chronic pancreatitis between 2011 and 2018 were identified from an institutional surgical database. Patient demographics, clinical indices, and perioperative computed tomography scans were collected. Myopenia and myosteatosis were measured at the L3 vertebral level. Regression analysis was used to identify risk factors for major complications (Clavien-Dindo ≥3a) and length of stay. RESULTS Seventy-five patients were identified. Toxic-metabolic or obstructive causes were the main underlying etiologies. Thirty patients were myopenic (40%), and 36 patients were myosteatotic (48%). Sixteen patients (21%) had a major complication. Median length of stay was 10 days. Both myopenia and myosteatosis were associated with major complications (hazard ratio = 7.85, 95% confidence interval: 1.91-32.29, P = .004 and hazard ratio = 4.351, 95% confidence interval: 1.22-15.52, P = .023). Myosteatosis was associated with increased length of stay (parameter estimate = 0.297, 95% confidence interval: 0.012-0.583, P = .041). CONCLUSION Myopenia and myosteatosis were common and significant risk factors for adverse postoperative events. Preoperative muscle assessment may help in the risk stratification of surgical patients and identify patients that require preoperative nutritional and physical optimization.
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Affiliation(s)
- Stephen J O'Brien
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY; Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland.
| | - Neal Bhutiani
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - J Isaac Young
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Prejesh Phillips
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Kalyn H Weaver
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - David Kline
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Gary C Vitale
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
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Kelliher LJS, Krige A. Anaesthesia for Pancreatic Surgery. Anesthesiol Clin 2022; 40:107-117. [PMID: 35236575 DOI: 10.1016/j.anclin.2021.11.005] [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: 06/14/2023]
Abstract
This article provides a broad perspective on the salient perioperative issues encountered when caring for patients undergoing pancreatic surgery in the setting of pancreatic cancer. It describes the epidemiology of pancreatic cancer, the indications for and evolution of pancreatic resection surgery, the challenges faced perioperatively including patient selection, optimization, anesthetic considerations, postoperative analgesia, fluid management, and nutrition and discusses some of the common complications and their management. It finishes by outlining the future directions for research and development required to continue improving outcomes for these patients.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7AS, UK.
| | - Anton Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK
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20
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Joshi R, Thomas M, Patkar S, Gupta AM, Panhale K, Rane PP, Ambulkar R, Goel M, Shrikhande SV, Agarwal V. Impact of enhanced recovery pathway in 408 gallbladder cancer resections. HPB (Oxford) 2022; 24:47-56. [PMID: 34187721 DOI: 10.1016/j.hpb.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/16/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gallbladder cancer (GBC) is the sixth most common gastrointestinal malignancy with poor prognosis. Enhanced Recovery Pathway (ERP) is associated with improved outcomes following abdominal surgical procedures. Currently, there is no study evaluating ERP in patients undergoing GBC surgery. The objective was to assess compliance with ERP elements and evaluate its impact on postoperative outcomes. METHODS Prospective study conducted from February 2014-2019, including elective GBC surgery. Team was educated prior to ERP implementation. Compliance with the protocol, functional gastrointestinal (GI) recovery, mobilisation, and postoperative outcomes were recorded. Impact of degree of compliance (more or less than 80%) with ERP and postoperative outcomes was evaluated. RESULTS In 408 patients, compliance with ERP was 84.6% (53.8-100%). Compliance >80% with ERP elements was observed in 245 patients (60%). Patients with >80% compliance had lower rate of minor (18.8% vs. 27%, p = 0.050) and significantly less major (0.8% vs. 6.1%, p = 0.002) and postoperative stay (5.84 ± 4.86 vs. 7.55 ± 6.6 days, p < 0.001) and earlier functional GI recovery. Intraoperative blood loss more than 600 ml, lower compliance (<80%) with ERP and preoperative albumin independently predicted postoperative complications. CONCLUSION This study demonstrates safety and efficacy of enhanced recovery pathway in gallbladder cancer. Higher compliance with the pathway was associated with significantly improved postoperative outcomes following gallbladder cancer surgery.
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Affiliation(s)
- Riddhi Joshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Martin Thomas
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Shraddha Patkar
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Amit M Gupta
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Karuna Panhale
- Research Nurse, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Pallavi P Rane
- Scientific Assistant (Statistics), Clinical Research Secretariat, Tata Memorial Centre, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Kharghar, Navi Mumbai 410210, India
| | - Reshma Ambulkar
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Mahesh Goel
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India
| | - Vandana Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Marg, Parel, Mumbai 400012, India.
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Takchi R, Cos H, Williams GA, Woolsey C, Hammill CW, Fields RC, Strasberg SM, Hawkins WG, Sanford DE. Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay. HPB (Oxford) 2022; 24:65-71. [PMID: 34183246 PMCID: PMC9446414 DOI: 10.1016/j.hpb.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. METHODS Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. RESULTS 494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615). CONCLUSION ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.
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Affiliation(s)
- Rony Takchi
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Heidy Cos
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Cheryl Woolsey
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.
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Dagorno C, Montalva L, Ali L, Brustia R, Paye-Jaquen A, Pio L, Bonnard A. Enhancing recovery after minimally invasive surgery in children: A systematic review of the literature and meta-analysis. J Pediatr Surg 2021; 56:2157-2164. [PMID: 34030881 DOI: 10.1016/j.jpedsurg.2021.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/23/2021] [Accepted: 04/05/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) has been widely implemented after minimally invasive surgeries (MIS) in adults. The aim of this study was to evaluate the current evidence available on ERAS after MIS in children. METHODS Using a defined search strategy (PubMed, Cochrane, Scopus), we performed a systematic review of the literature, searching for studies reporting on ERAS after MIS (thoracoscopy, laparoscopy, retroperitoneoscopy) in children (1975-2019). This study was registered with PROSPERO-international prospective register of systematic reviews. A meta-analysis was conducted using comparative studies for length of stay (LOS), complication rates, and readmission rates. RESULTS Of 180 abstracts screened, 20 full-text articles were analyzed, and 9 were included in our systematic review (1 randomized controlled trial, 3 prospective, and 5 retrospective studies), involving a total number of 531 patients. ERAS has been applied to laparoscopy for digestive (n = 7 studies) or urologic surgeries (n = 1), as well as thoracoscopy (n = 1). Mean LOS was decreased in ERAS children compared to controls (6 studies, -1.12 days, 95%IC: -1.5 to -0.82, p < 0.00001). There was no difference in complication rates between ERAS children and control children (5 studies, 13% vs 14%, OR = 0.84, 95%CI: 0.49-1.44, p = 0.52). The 30-day readmission rate was decreased in ERAS children compared to controls (6 studies, 4% vs 10%, OR = 0.34, 95%CI: 0.18-0.66, p = 0.001). CONCLUSIONS Although the evidence regarding ERAS in MIS is scarce, these protocols seem safe and effective, by decreasing LOS and 30-day readmission rate, without increasing post-operative complication rates.
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Affiliation(s)
- Claire Dagorno
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France.
| | - Louise Montalva
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France
| | - Liza Ali
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France
| | - Raffaele Brustia
- Paris University, Paris, France; Department of Colorectal and Hepatobiliary Surgery, Henri-Mondor University Hospital, Creteil, France
| | - Annabel Paye-Jaquen
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France; Paris University, Paris, France
| | - Luca Pio
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France; Paris University, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, 48 boulevard Sérurier, 75019 Paris, France; Paris University, Paris, France; UFR de Médecine, Université Paris Diderot-Sorbonne Paris Cité, Paris, France
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Tan YY, Liaw F, Warner R, Myers S, Ghanem A. Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2021; 45:2096-2115. [PMID: 33821314 DOI: 10.1007/s00266-021-02233-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery. OBJECTIVES To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction. DATA SOURCES Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies. INCLUSION CRITERIA All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language. OUTCOME MEASURES The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications. RESULTS Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported. CONCLUSION ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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A 2-Year Experience With Enhanced Recovery After Surgery: Evaluation of Compliance and Outcomes in Pancreatic Surgery. J Nurs Care Qual 2021; 36:E24-E28. [PMID: 32282506 DOI: 10.1097/ncq.0000000000000487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs reduce recovery time, length of stay (LOS), and complications after major surgical procedures. PURPOSE We evaluated our 2-year experience with a newly implemented comprehensive ERAS program at a high-volume center after pancreatic surgery. METHODS Outcomes, cost, and compliance metrics were assessed in 215 patients who underwent elective pancreatic surgery (pre-ERAS; n = 99; post-ERAS: n = 116). Mann-Whitney U and χ2 tests were used to evaluate continuous and categorical variables. RESULTS There were significant decreases in LOS and cost in the post-ERAS cohorts. There were significant increases in compliance with ERAS implementation. Postoperative complication, readmission, and survival rates did not increase. CONCLUSIONS Implementation of ERAS at a large-volume hospital may improve compliance and reduce costs and LOS without increasing adverse outcomes.
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25
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Ergenc M, Karpuz S, Ergenc M, Yegen C. Enhanced recovery after pancreatic surgery: A prospective randomized controlled clinical trial. J Surg Oncol 2021; 124:1070-1076. [PMID: 34287900 DOI: 10.1002/jso.26614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES The enhanced recovery after surgery (ERAS) protocol is a perioperative care bundle designed to achieve early healing after surgical procedures. This study aims to investigate the effect of the ERAS protocol on postoperative complications, length of hospital stay (LOS), and readmission rates in pancreatic surgery patients. METHODS The study was designed as a prospective and randomized controlled study between January 2016 and November 2018 on pancreatic surgery patients. A total of 38 patients were analyzed, 18 of whom were in the ERAS group and 20 in the control group. Patient demographics, intraoperative variables, and postoperative outcomes were recorded. RESULTS The groups were similar regarding age, sex, surgery type, American Society of Anesthesiologists scores, and laboratory results. There was no significant difference in the intraoperative variables. Early oral feeding was preferred, mostly in the ERAS group compared to the control group. Perioperative complication rates, including delayed gastric emptying and pancreatic fistula, LOS, and readmission rates, were similar between the two groups. CONCLUSIONS The ERAS protocol provided a minimal decrease in the total complication rates and had no effect on severe complications. Therefore, the ERAS protocol seems feasible and can be applied safely in pancreatic surgery patients.
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Affiliation(s)
- Muhammer Ergenc
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sakir Karpuz
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Merve Ergenc
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Cumhur Yegen
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
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Kone LB, Maker VK, Banulescu M, Maker AV. Epidural Analgesia Is Associated with Prolonged Length of Stay After Open HPB Surgery in Over 27,000 Patients. J Gastrointest Surg 2021; 25:1716-1726. [PMID: 32725519 DOI: 10.1007/s11605-020-04751-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control. RESULTS Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality. CONCLUSION In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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Li J, Lin F, Yu S, Marshall AP. Enhanced recovery protocols in patients undergoing pancreatic surgery: An umbrella review. Nurs Open 2021; 9:932-941. [PMID: 34105896 PMCID: PMC8859084 DOI: 10.1002/nop2.923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/17/2021] [Accepted: 04/20/2021] [Indexed: 11/09/2022] Open
Abstract
Aim To identify, synthesize and appraise the systematic reviews of ERAS for patients undergoing pancreatic surgery and facilitate ERAS implementation. Design An umbrella review was used to identify systematic reviews. Methods A systematic search following the PRISMA guidelines was used to search databases including PubMed, Embase, Cochrane Library, CINAHL, CNKI, WanFang and VJIP. AMSTAR 2 was used to appraise the quality of included reviews. Results Ten systematic reviews were included. The quality of all included systematic reviews was rated as “critically low.” The most frequently reported ERAS elements were epidurals analgesia/PCA (9/10), goal‐directed mobilization (9/10) and early removal of drains (9/10). Only one review mentioned audit protocol compliance. None of the included reviews reported discharge standards. Ten reviews reported decreased length of stay, seven reviews reported lower hospital costs, and six reviews reported decreased total complications rate. There were no adverse effects reported.
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Affiliation(s)
- Jing Li
- Nursing department, Peking University First Hospital, Beijing, China
| | - Frances Lin
- School of Nursing, Midwifery, and Paramedicine, University of the Sunshine Coast, Maroochydore DC, QLD, Australia.,Sunshine Coast Health Institute, Birtinya, QLD, Australia.,School of Nursing and Midwifery, Griffith University, Southport, QLD, Australia
| | - Shuhui Yu
- Urological Ward, Peking University First Hospital, Beijing, China
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Southport, QLD, Australia.,Nursing and Midwifery Education and Research Unit, Gold Coast Health, Southport, QLD, Australia
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Tabchouri N, Bouquot M, Hermand H, Benoit O, Loiseau JC, Dokmak S, Aussilhou B, Gaujoux S, Turrini O, Delpero JR, Sauvanet A. A Novel Pancreatic Fistula Risk Score Including Preoperative Radiation Therapy in Pancreatic Cancer Patients. J Gastrointest Surg 2021; 25:991-1000. [PMID: 32314240 DOI: 10.1007/s11605-020-04600-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most serious complication following pancreaticoduodenectomy (PD). Identifying patients at high or low risk of developing POPF is important in perioperative management. This study aimed to determine a predictive risk score for POPF following PD, and compare it to preexisting scores. METHODS All patients who underwent open PD from 2012 to 2017 in two high-volume centers were included. The training dataset was used for the development of the POPF predictive risk score (using the 2016 ISGPS definition), while the testing dataset was used for external validation. The proposed score was compared to the fistula risk score (FRS), the NSQIP-modified FRS (mFRS), and the alternative FRS (aFRS). RESULTS Overall, 448 and 213 patients were included in the training and testing datasets, respectively. A probabilistic predictive risk score was developed using four independent POPF risk factors (increasing age, no preoperative radiation therapy, soft pancreatic stump, and decreasing main pancreatic duct diameter). The discriminative capacities of the new score, FRS, mFRS, and aFRS were similar (AUC ranging from 0.73 to 0.79 in the training cohort and from 0.73 to 0.76 in the testing cohort). However, the new score identified more specifically patients at low risk of POPF compared with other scores, in both cohorts, with a 6% false-negative rate. CONCLUSIONS Preoperative radiation therapy is an independent protective factor of POPF following PD. It should be included in the risk score of POPF to identify more precisely patients at low risk for this complication.
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Affiliation(s)
- Nicolas Tabchouri
- Department of HPB Surgery, Hôpital Beaujon, Paris, France.,Department of Digestive Surgery, Hôpital Trousseau, Tours, France
| | - Morgane Bouquot
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Hélène Hermand
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | - Olivier Benoit
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | | | - Safi Dokmak
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | | | | | - Olivier Turrini
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Jean Robert Delpero
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Alain Sauvanet
- Department of HPB Surgery, Hôpital Beaujon, Paris, France. .,University Paris, Paris, France. .,AP-HP, Department of HBP Surgery, DIGEST Medico-Universitary Department, Hôpital Beaujon APHP, 100 boulevard du Général Leclerc, 92110, Clichy, France.
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery. Anesth Analg 2021; 132:182-193. [PMID: 32665473 DOI: 10.1213/ane.0000000000004980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. METHODS A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. RESULTS Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. CONCLUSIONS The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.
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Pineda-Solis K, Burchard PR, Ruffolo LI, Schoeniger LO, Linehan DC, Moalem J, Galka E. Early Prediction of Length of Stay After Pancreaticoduodenectomy. J Surg Res 2020; 260:499-505. [PMID: 33358193 DOI: 10.1016/j.jss.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD). METHODS We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors". RESULTS A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008). CONCLUSIONS ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.
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Affiliation(s)
- Karen Pineda-Solis
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Paul R Burchard
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luis I Ruffolo
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luke O Schoeniger
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - David C Linehan
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacob Moalem
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Galka
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Shah R, Diaz A, Tripepi M, Bagante F, Tsilimigras DI, Machairas N, Sigala F, Moris D, Barreto SG, Pawlik TM. Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition. J Gastrointest Surg 2020; 24:2874-2883. [PMID: 32705613 DOI: 10.1007/s11605-020-04748-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care. METHODS The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs. RESULTS The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care. CONCLUSIONS The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.
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Affiliation(s)
- Rohan Shah
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Marzia Tripepi
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Fragiska Sigala
- Department of Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Mackay TM, Latenstein AEJ, Bonsing BA, Bruno MJ, van Eijck CHJ, Groot Koerkamp B, de Hingh IHJT, Homs MYV, van Hooft JE, van Laarhoven HW, Molenaar IQ, van Santvoort HC, Stommel MWJ, de Vos-Geelen J, Wilmink JW, Busch OR, van der Geest LG, Besselink MG. Nationwide compliance with a multidisciplinary guideline on pancreatic cancer during 6-year follow-up. Pancreatology 2020; 20:1723-1731. [PMID: 33069583 DOI: 10.1016/j.pan.2020.10.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/27/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Compliance with national guidelines on pancreatic cancer management could improve patient outcomes. Early compliance with the Dutch guideline was poor. The aim was to assess compliance with this guideline during six years after publication. MATERIALS AND METHODS Nationwide guideline compliance was investigated for three subsequent time periods (2012-2013 vs. 2014-2015 vs. 2016-2017) in patients with pancreatic cancer using five quality indicators in the Netherlands Cancer Registry: 1) discussion in multidisciplinary team meeting (MDT), 2) maximum 3-week interval from final MDT to start of treatment, 3) preoperative biliary drainage when bilirubin >250 μmol/L, 4) use of adjuvant chemotherapy, and 5) chemotherapy for inoperable disease (non-metastatic and metastatic). RESULTS In total, 14 491 patients were included of whom 2290 (15.8%) underwent resection and 4561 (31.5%) received chemotherapy. Most quality indicators did not change over time: overall, 88.8% of patients treated with curative intent were discussed in a MDT, 42.7% were treated with curative intent within the 3-week interval, 62.7% with a resectable head tumor and bilirubin >250 μmol/L underwent preoperative biliary drainage, 57.2% received chemotherapy after resection, and 36.6% with metastatic disease received chemotherapy. Only use of chemotherapy for non-metastatic, non-resected disease improved over time (23.4% vs. 25.6% vs. 29.7%). CONCLUSION Nationwide compliance to five quality indicators for the guideline on pancreatic cancer management showed little to no improvement during six years after publication. Besides critical review of the current quality indicators, these outcomes may suggest that a nationwide implementation program is required to increase compliance to guideline recommendations.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Deparment of Surgery, Leids University Medical Center, Leiden, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Allen G. Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Versus Conventional Care in Patients Undergoing Radical Prostatectomy. AORN J 2020; 112:711-714. [PMID: 33252807 DOI: 10.1002/aorn.13268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
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Winer LK, Cortez AR, Ahmad SA, Wima K, Olowokure O, Latif T, Kharofa J, Patel SH. Evaluating the Impact of ESPAC-1 on Shifting the Paradigm of Pancreatic Cancer Treatment. J Surg Res 2020; 259:442-450. [PMID: 33059910 DOI: 10.1016/j.jss.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 08/09/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2004, the European Study Group for Pancreatic Cancer (ESPAC)-1 long-term data concluded that adjuvant chemotherapy provided a survival benefit for patients with pancreatic ductal adenocarcinoma (PDAC), whereas adjuvant chemoradiation was associated with worse overall survival. In this study, we investigated how long it took for US practice patterns to change following this trial. METHODS The National Cancer Database was used to identify patients with stage I-III PDAC who underwent R0 or R1 resection followed by adjuvant chemotherapy or chemoradiation between 1998 and 2015. A multivariate analysis was performed to determine predictors of receiving adjuvant chemoradiation in the post-ESPAC-1 era. RESULTS Between 1998 and 2015, adjuvant chemotherapy use increased from 2.9% to 51.6%, whereas adjuvant chemoradiation decreased from 49.5% to 22.9%. In 2010, adjuvant chemotherapy utilization surpassed that of chemoradiation. For patients diagnosed in the post-ESPAC-1 era, adjuvant chemotherapy (n = 7733) and chemoradiation (n = 6969) groups were compared. Patients who underwent adjuvant chemoradiation were younger, had private insurance, underwent surgery at nonacademic centers, and had more pathologically advanced cancers (all P < 0.01). After 2010, R1 resection was the strongest independent predictor of adjuvant chemoradiation use by multivariate analysis (OR 2.05, CI 1.8-2.3, P < 0.01). CONCLUSIONS Adjuvant chemotherapy use exceeded that of adjuvant chemoradiation 6 y after the final publication of ESPAC-1 in 2004, highlighting the challenges of disseminating and adopting clinical data. After 2010, R1 disease was the most significant predictor of receiving adjuvant chemoradiation. Prospective studies are underway to definitively address the role of adjuvant chemoradiation in PDAC.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Syed A Ahmad
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olubenga Olowokure
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Tahir Latif
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Sameer H Patel
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2020; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.,Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Aristizábal-Linares JP, Quevedo-Vélez C, Sánchez-Zapata P. Quality of life analysis after Whipple procedure. Retrospective cohort study. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Patient reported outcomes establish the patient’s own perception about his/her health and enable the development of policies designed to improve health/disease processes. These are particularly helpful in the case of diseases with a significant impact on the patient’s quality of life.
Objective: To compare the quality of life scores assessed using the EQ-5D-5L questionnaire in patients undergoing cephalic duodenopancreatectomy (Whipple procedure) and laparoscopic cholecystectomies in the same hospital.
Methodology: Retrospective cohort trial between July 2018 and February 2020. Patients programmed for cephalic duodenopancreatectomy were included, regardless of the type of pathology, and over 18 years old. Patients with carcinomatosis or vascular infiltration were excluded. The EQ-5D-5L was administered following Whipple surgery and compared against a control group (laparoscopic cholecystectomy). The demographic characteristics, the diagnosis, hospital stay and 60-day mortality were assessed.
Results: A total of 68 patients were included. The most frequent diagnosis was pancreatic cancer (30 %) in the Whipple group and lithiasis (100 %) in the control group. In the five dimensions assessed, there were no differences in terms of mobility (OR: 0.41, 95 % CI [0.30-0.57], p = 0.103) and in terms of personal care (OR: 0.42, 95 % CI [0.32-0.58], p = 0.254). There was a difference in daily life activities (OR: 0.38, 95 % CI [0.27-0.54], p = 0.017), pain/malaise (OR: 2.33, 95 % CI [0.99-5.48]), p = 0.013 and anxiety/depression (OR: 0.39, 95 % CI [0.28-0.55], p = 0.019). The overall health perception was 80 points for Whipple (IQR 60-90) vs. 100 points for the control group (IQR 90-100).
Conclusions: Patients undergoing a Whipple procedure experience a health perception slightly lower than patients undergoing laparoscopic cholecystectomy. This difference may be associated with increased pain, anxiety/depression and a reduction in their activities of daily life. The administration of the EQ-5D-5L questionnaire to measure quality of life is a friendly tool that used be used routinely to plan activities aimed at improving medical care.
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Abe K, Kitago M, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Yokose T, Endo Y, Kitagawa Y. High risk pathogens and risk factors for postoperative pancreatic fistula after pancreatectomy; a retrospective case-controlled study. Int J Surg 2020; 82:136-142. [DOI: 10.1016/j.ijsu.2020.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022]
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Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution. World J Surg 2020; 45:23-32. [DOI: 10.1007/s00268-020-05765-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 12/19/2022]
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41
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Dinh KH, McAuliffe PF, Boisen M, Esper SA, Subramaniam K, Steiman JG, Soran A, Johnson RR, Holder-Murray JM, Diego EJ. Post-operative Nausea and Analgesia Following Total Mastectomy is Improved After Implementation of an Enhanced Recovery Protocol. Ann Surg Oncol 2020; 27:4828-4834. [DOI: 10.1245/s10434-020-08880-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 07/02/2020] [Indexed: 12/19/2022]
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Smith AE, Heiss K, Childress KJ. Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study. J Pediatr Adolesc Gynecol 2020; 33:403-409. [PMID: 32061749 DOI: 10.1016/j.jpag.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use. DESIGN As a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria. SETTING Large academic children's hospital. PARTICIPANTS Patients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period. INTERVENTIONS An ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service. MAIN OUTCOME MEASURES Patient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures. RESULTS A total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit. CONCLUSION Implementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.
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Affiliation(s)
| | - Kurt Heiss
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA
| | - Krista J Childress
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Emory University, Atlanta, GA.
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Enhanced Recovery After Pancreatic Surgery Does One Size Really Fit All? A Clinical Score to Predict the Failure of an Enhanced Recovery Protocol After Pancreaticoduodenectomy. World J Surg 2020; 44:3600-3606. [PMID: 32734454 PMCID: PMC7527369 DOI: 10.1007/s00268-020-05693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2020] [Indexed: 12/19/2022]
Abstract
Background The inability to comply with enhanced recovery protocols (ERp) after pancreaticoduodenectomy (PD) is a real but understated issue. Our goal is to report our experience and a potential tool to predict ERp failure in order to better characterize this problem. Methods From January 1, 2014, to January 31, 2016, 205 consecutive patients underwent PD in our center and were managed according to an ERp. Failure to comply with postoperative protocol items was defined as any of: no active ambulation on postoperative day 1 (POD1); less than 4 h out of bed on POD2; removal of nasogastric tube and bladder catheter after POD1 and POD3, respectively; reintroduction of oral feeding after POD4; and continuation of intravenous infusions after POD4. Data were collected in a prospective database. Results Taking in consideration the number of failed items and the length of stay, we defined failure of the ERp as no compliance to two or more items. A total of 116 patients (56.6%) met this definition of failure. We created a predictive model consisting of age, BMI, operative time, and pancreatic stump consistency. These variables were independent predictors of failure (OR 1.03 [1.001–1.06] p = 0.01; OR 1.11 [1.01–1.22] p = 0.03; OR 1.004 [1.001–1.009] p = 0.02 and OR 2.89 [1.48–5.67] p = 0.002, respectively). Patient final score predicted the failure of the ERp with an area under the ROC curve of 0.747. Conclusions It seems to be possible to predict ERp failure after PD. Patients at high risk of failure may benefit more from a specific ERp.
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Early drain removal after major pancreatectomy reduces postoperative complications: a single-center, randomized, controlled trial. JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Nutritional considerations for the management of the older person with hepato-pancreatico-biliary malignancy. Eur J Surg Oncol 2020; 47:533-538. [PMID: 32362465 DOI: 10.1016/j.ejso.2020.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/04/2020] [Accepted: 04/14/2020] [Indexed: 01/06/2023] Open
Abstract
Malnutrition and cancer cachexia are prevalent in older people with hepato-pancreatico-biliary (HPB) malignancy, with the resultant loss of muscle mass and function accelerating normal age-associated losses. Unintentional weight loss may be missed in patients with pre-illness obesity, delaying diagnosis and limiting treatment potential and access. Sarcopenia and/or sarcopenic obesity increase the risk of dose-limiting chemotherapy toxicity, post-operative mortality and overall survival. The aetiology of malnutrition and weight loss is multi-factorial in patients with HPB malignancy, necessitating systematic evaluation of endocrine and exocrine function, and multi-modal therapeutic strategies. Prehabilitation aims to reduce the complications and side effects associated with treatment, aid recovery and improve quality of life, with the greatest benefits potentially being seen in high risk groups, such as people who are older and frail. Post-operatively, individualised nutritional support therapies targeting the preservation of weight and muscle indices are required to improve post-operative morbidity, and avoid delay or early cessation of any necessary adjuvant therapy.
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Kubitz JC, Schulte-Uentrop L, Zoellner C, Lemke M, Messner-Schmitt A, Kalbacher D, Sill B, Reichenspurner H, Koell B, Girdauskas E. Establishment of an enhanced recovery after surgery protocol in minimally invasive heart valve surgery. PLoS One 2020; 15:e0231378. [PMID: 32271849 PMCID: PMC7145109 DOI: 10.1371/journal.pone.0231378] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/21/2020] [Indexed: 12/13/2022] Open
Abstract
Protocols for “Enhanced recovery after surgery (ERAS)” are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.
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Affiliation(s)
- Jens C. Kubitz
- Department of Anaesthesiology, University Medical Center Eppendorf, Hamburg, Germany
- * E-mail:
| | | | - Christian Zoellner
- Department of Anaesthesiology, University Medical Center Eppendorf, Hamburg, Germany
| | - Melanie Lemke
- Department of Physiotherapy, University Medical Center Eppendorf, Hamburg, Germany
| | | | - Daniel Kalbacher
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Björn Sill
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Benedikt Koell
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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Martin D, Joliat GR, Halkic N, Demartines N, Schäfer M. Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons. HPB (Oxford) 2020; 22:75-82. [PMID: 31257012 DOI: 10.1016/j.hpb.2019.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/02/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons. METHODS A web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks. RESULTS In total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support. CONCLUSION Management of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.
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Affiliation(s)
- David Martin
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | | | - Nermin Halkic
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland.
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
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Casey P, Chaudhury MP, Khan A, Amin J, Afzal A, Corallo C, Sebastian D, Atkinson M, Subar D. The impact of perioperative inotropes on the incidence of pancreatic leak following pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:392-396. [PMID: 31825007 PMCID: PMC6893053 DOI: 10.14701/ahbps.2019.23.4.392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/18/2019] [Accepted: 07/25/2019] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Pancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy. Methods Retrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula. Results One-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size. Conclusions Perioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.
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Affiliation(s)
- Patrick Casey
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | | | - Asaad Khan
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Jebran Amin
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Abdul Afzal
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Carmello Corallo
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Domnic Sebastian
- Department of Anaesthesia, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Matthew Atkinson
- Department of Anaesthesia, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Daren Subar
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
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Boisen ML, McQuaid AJ, Esper SA, Holder-Murray J, Zureikat AH, Hogg ME, Paronish J, Subramaniam K. Intrathecal Morphine Versus Nerve Blocks in an Enhanced Recovery Pathway for Pancreatic Surgery. J Surg Res 2019; 244:15-22. [DOI: 10.1016/j.jss.2019.05.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 05/01/2019] [Accepted: 05/30/2019] [Indexed: 01/31/2023]
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Enhanced recovery after surgery (ERAS) versus standard recovery for elective gastric cancer surgery: A meta-analysis of randomized controlled trials. Surg Oncol 2019; 32:75-87. [PMID: 31786352 DOI: 10.1016/j.suronc.2019.11.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/03/2019] [Accepted: 11/17/2019] [Indexed: 02/08/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols have been effective in improving postoperative recovery after major abdominal surgeries including colorectal cancer surgery, however its impact after gastric cancer surgery is unclear. A systematic review and meta-analysis was conducted to evaluate the effect of ERAS after gastric cancer surgery. Medline, EMBASE, CENTRAL, and PubMed was searched from database inception to December 2018. Randomized controlled trials (RCTs) comparing ERAS versus standard care in gastric cancer surgery were included. Outcomes included the postoperative length of stay (LOS), hospital costs, time to first flatus, defecation, oral intake, and ambulation after surgery, and complications. Pooled estimates were calculated using random-effects meta-analysis. The GRADE approach assessed overall quality of evidence. 18 RCTs involving 1782 patients were included. ERAS significantly reduced the LOS (Mean Difference (MD) -1.78 days, 95%CI -2.17 to -1.40, P < 0.0001), reduced hospital costs (MD -650 U S. dollars, 95%CI -840 to -460, P < 0.0001), and reduced time to first flatus, defecation, ambulation, and oral intake. ERAS had significantly lower rates of pulmonary infections (Risk Ratio (RR) 0.48, 95%CI 0.28 to 0.82, P = 0.007), but not surgical site infections, anastomotic leaks, and postoperative complications. However, ERAS significantly increased readmissions (RR 2.43, 95%CI 1.09 to 5.43, P = 0.03). The quality of evidence was low to moderate for all outcomes. Implementation of an ERAS protocol may reduce LOS, costs, and time to return of function after gastric cancer surgery compared to conventional recovery. However, ERAS may increase the number of postoperative readmissions, albeit with no impact on the rate of postoperative complications.
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