“Fast-Track” Abdominal Aortic Aneurysm Repair

A systematic review of enhanced recovery after surgery for vascular operations

BACKGROUND

Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis.

RESULTS

In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012).

CONCLUSIONS

Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done.

Endovascular versus “Fast-Track” Abdominal Aortic Aneurysm Repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 ±0.13 vs 6.1 ±0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 ±7.4 vs 158 ±6.8 minutes, p<0.0001), with a greater volume of blood (1.8 ±0.29 vs 0.32 ±0.24 units, p=0.0005), colloid (565 ±89 vs 32 ±22 cc, p<0.0001), and crystalloid transfusions (4,625 ±252 vs 2,627 ±170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 ±0.08 vs 1.8 ±0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 ±0.10 vs 0.87 ±0.10 days, p=0.01), but floor (2.1 ±0.23 vs 2.6 ±0.21 days, p=0.17), and total hospital lengths of stay (2.8 ±0.32 vs 3.4 ±0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track ($10,205 ±$736 vs $20,640 ±$1,206, p<0.0001) leading to greater overall hospital earnings ($6,141 ±$1,280 vs $107 ±$1,940, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.

Mini-invasive aortic surgery: personal experience

OBJECTIVE

In this study, we retrospectively evaluated our experience in minilaparotomy (MINI) and compared the results with conventional open repair (OPEN).

METHODS

From January 2005 to December 2012, we surgically treated 234 consecutive patients with elective infrarenal abdominal aortic aneurysms, 195 men and 39 women, with a mean age of 74 years. Inclusion criteria for MINI were not ruptured abdominal aortic aneurysm, increased surgical risk, anatomical limits for endovascular repair, no previous surgical invasion of the abdominal cavity, and no requirement for concomitant abdominal surgical invasion. Surgical treatment was OPEN in 113 patients (48.3%) and MINI through an 8- to 14-cm incision in 121 patients (51.7%). Epidural anesthesia has been added in 26.5% and in 19.3% of the MINI and OPEN patients, respectively. Mortality, complications, aortic clamping time, operative time, need for postoperative morphine therapy, time to solid diet, and length of hospital stay were registered.

RESULTS

The MINI has been performed in all patients selected, with 72 aortoaortic grafts and 49 aortobisiliac grafts. Early mortality was 1.6% versus 3.5% (P > 0.5); 1-, 3-, and 5-year mortality were 7% versus 9%, 19% versus 22%, and 29% versus 34% (P > 0.5); complications were 12.2% versus 26.6% (P > 0.05); mean (SD) clamping time was 48 (12) versus 44 (14) minutes (P > 0.5); mean (SD) operative time was 218.72 (41.95) versus 191.44 (21.73) minutes (P > 0.025); mean (SD) estimated intraoperative blood loss was 425.64 (85.95) versus 385.30 (72.41) mL (P > 0.1); mean (SD) morphine consumption in the group given epidural and the group not given epidural was 0 (2) and 2 (2) mg intravenously (IV) versus 2 (4) (P < 0.5) and 4 (3) mg IV (P > 0.1); mean (SD) ambulation was 2.1 (0.6) versus 4.1 (2.7) (P < 0.5); mean (SD) time to solid diet was 2.1 (0.4) versus 3.5 (1.6) (P < 0.5); and mean (SD) length of hospital stay was 4.9 (1.64) versus 7.35 (1.95) days (P > 0.05), in the MINI and OPEN groups, respectively. Postoperative hernia at 3 years was 18% versus 23% in the MINI and OPEN groups (P < 0.5), respectively.

CONCLUSIONS

The MINI gives the patients a significantly shorter period of recovery with the quality and safety of the OPEN. This experience suggested extending the indication to all surgical candidates without local limitations.

Patient education videos for elective colorectal surgery: results of a randomized controlled trial

AIM

Recent advances in surgery have focused on peri-operative care and interventions to improve outcome following surgery. Psychological preparation has a positive impact on recovery and incorporates a range of strategies with dissemination of information as one of the key elements. Information can be given verbally, through printed information or through use of a video. Traditionally, reliance has been on the use of written material as an adjunct to patient education in clinic. The current study is a randomized trial on the use of video education in patients undergoing elective colorectal resection within an enhanced recovery programme.

METHOD

Sixty-five eligible patients undergoing elective colorectal surgery were identified and 61 were randomized between August 2010 and August 2011 to either video and information leaflets or information leaflets alone. A fast track protocol was established for all the patients. Clinicians in charge of postoperative recovery were blinded. Standard discharge criteria were employed for all patients.

RESULTS

Of 61 patients randomized, one dropped out and outcomes on 60 were analysed. There was no difference in baseline characteristics between the groups (age, P = 0.964; body mass index, P = 0.829). Twenty-eight (91%) patients in the video group had left sided resections while two (6%) had right sided resections. Nineteen (66%) in the non-video group had left sided resections while nine (31%) had right sided resections. One (3%) patient in the non-video group and one (3%) in the video group had a total colectomy. Fourteen (45%) patients in the video group and 12 (41%) in the non-video group had surgery completed laparoscopically. There was no difference in the primary (median hospital stay 5 vs 5 days; P = 0.239) or the secondary outcome measures (pain score on movement, P = 0.338; pain score at rest, P = 0.989; nausea score, P = 0.74; epidural use, P = 0.984; paracetamol use, P = 0.44; voltarol use, P = 0.506) between the groups.

CONCLUSION

Use of video education in the psychological preparation of patients undergoing elective colorectal surgery does not improve short-term outcomes.

Patient optimization for gastrointestinal cancer surgery

BACKGROUND

Although surgical resection remains the central element in curative treatment of gastrointestinal cancer, increasing emphasis and resource has been focused on neoadjuvant or adjuvant therapy. Developments in these modalities have improved outcomes, but far less attention has been paid to improving oncological outcomes through optimization of perioperative care.

METHODS

A narrative review is presented based on available and updated literature in English and the authors' experience with enhanced recovery research.

RESULTS

A range of perioperative factors (such as lifestyle, co-morbidity, anaemia, sarcopenia, medications, regional analgesia and minimal access surgery) are modifiable, and can be optimized to reduce short- and long-term morbidity and mortality, improve functional capacity and quality of life, and possibly improve oncological outcome. The effect on cancer-free and overall survival may be of equal magnitude to that achieved by many adjuvant oncological regimens. Modulation of core factors, such as nutritional status, systemic inflammation, and surgical and disease-mediated stress, probably influences the host's immune surveillance and defence status both directly and through reduced postoperative morbidity.

CONCLUSION

A wider view on long-term effects of expanded or targeted enhanced recovery protocols is warranted.

An update on the 'fast-track' abdominal aortic aneurysm repair

Patients who have unfavourable anatomy for endovascular repair of an abdominal aortic aneurysm require open repair. This is particularly the case for juxtarenal aortic aneurysms, or those patients with small or occluded iliac access vessels.An experience of 'fast-track' abdominal aortic aneurysm repair that was previously reported is updated in the present case. A retroperitoneal approach to the aorta is taken, using a small incision, and is followed by a patient care pathway protocol that demonstrated excellent results and a shortened length of stay. The present update on 56 patients is approximately double the previously reported experience.

Feasibility study of early oral intake after gastrectomy for gastric carcinoma

Purpose

Despite the compelling scientific and clinical data supporting the use of early oral nutrition after major gastrointestinal surgery, traditional bowel rest and intravenous nutrition for several postoperative days is still being used widely after gastric cancer surgery.

Materials and Methods

A phase II study was carried out to evaluate the feasibility and safety of postoperative early oral intake (water intake on postoperative days (POD) 1-2, and soft diet on POD 3) after a gastrectomy. The primary outcome was morbidity within 30 postoperative days, which was targeted at <25% based on pilot study data.

Results

The study subjects were 90 males and 42 females with a mean age 61.5 years. One hundred and four (79%) and 28 (21%) patients underwent a distal and total gastrectomy, respectively. The postoperative morbidity rate was within the targeted range (15.2%, 95% CI, 10.0~22.3%), and there was no hospital mortality. Of the 132 patients, 117 (89%) successfully completed a postoperative early oral intake regimen without deviation; deviation in 10 (8%) due to gastrointestinal symptoms and in five (4%) due to the management of postoperative complications. The mean times to water intake and a soft diet were 1.0±0.2 and 3.2±0.7 days, respectively, and the mean hospital stay was 10.0±6.1 days.

Conclusions

Postoperative early oral intake after a gastrectomy is feasible and safe, and can be adopted as a standard perioperative care after a gastrectomy. Nevertheless, further clinical trials will be needed to evaluate the benefits of early oral nutrition after upper gastrointestinal surgery.

Anesthesia for Open Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are the 13th leading cause of death in the United States 1 and approximately 40,000 patients undergo elective AAA repair each year.2 With the population aging, this number is expected to increase. Although the use of endovascular AAA repair is becoming more common, open repair, first reported by Dubost et al. in 1951 remains the gold standard.2 This chapter will review the etiology, risk factors, diagnosis, pathophysiology, operative technique, perioperative management, and postoperative complications of patients undergoing open AAA repair.

Measure what matters: institutional outcome data are superior to the use of surrogate markers to define "center of excellence" for abdominal aortic aneurysm repair

Outcome analysis is increasingly being used to develop health-care policy and direct patient referral. For example, the Leapfrog Group health-care quality initiative has proposed "evidence-based hospital" referral criteria for specific procedures including elective abdominal aortic aneurysm repair (AAA-R). These criteria include an annual hospital AAA operative volume exceeding 50 cases and provision of intensive care unit (ICU) care by board-certified intensivists. Outcomes after AAA-R are reportedly influenced by presentation (intact vs. ruptured), operative approach (endovascular vs. open, transperitoneal vs. retroperitoneal), surgeon subspecialty, case volume (hospital and surgeon), and provision of postoperative care by an intensivist. The purpose of this study was to compare our single-center results with those of high-volume centers to assess the validity of the concept that surrogate markers, such as case volume or intensivist involvement, can be used to estimate procedural outcome. A retrospective review was performed of AAA-Rs at one low-volume academic medical center from January 1994 to March 2005. Demographic data, aneurysm diameter and location, operative indications, and repair approach were documented. Postoperative complications, mortality rates, and hospital and ICU length of stay (LOS) were noted and compared to established benchmarks. During the study period, 270 patients underwent AAA-R (annual mean = 27 hospital cases and 13.4 cases/attending vascular surgeon). ICU care was provided by a dedicated vascular surgery service without routine intensivist involvement. Open, elective, infrarenal AAA-R was performed in 161 patients (60%), with a 2.5% hospital mortality rate (30-day, 3.1%). Thirty-three (12%) patients underwent elective endovascular aneurysm repair (EVAR), with no mortality. Both ICU (3.7 vs. 1.4 days, p = 0.03) and hospital (9.2 vs. 2.8 days, p = 0.002) LOS were significantly reduced after EVAR compared to open repair. Hospital LOS was significantly lower after open retroperitoneal repair compared to transperitoneal repair (6.1 vs. 10.3 days, p = 0.001). Thirty-five patients (13%) underwent ruptured AAA-R, with only 34.3% mortality (in-hospital and 30-day). Forty-one patients (15%) underwent repair of complex aortic aneurysms, with 14.1% mortality. There are increasing societal and economic pressures to direct patient referrals to "centers of excellence" for specific surgical procedures. Although our institution meets neither of the Leapfrog Group's proposed criteria, our mortality and LOS for both intact and ruptured infrarenal AAA-R are equivalent or superior to published benchmarks for high-volume hospitals. Individual institutional outcome results such as these suggest that patient referral and care should be based upon actual, carefully verified outcome data rather than utilization of surrogate markers such as case volume and subspecialist involvement in postoperative care.

Fast Track Open Aortic Surgery: Reduced Post Operative Stay with a Goal Directed Pathway

OBJECTIVE

Open aortic aneurysm repair is traditionally associated with an extended hospital stay. The aim of this study was to examine the feasibility of reducing post-operative stay through the implementation of a fast-track, goal directed, clinical pathway for elective open aortic surgery.

METHODS

A fast-track clinical pathway for aortic surgery was introduced in a regional vascular unit in September 2005. The pathway has daily goals and targets discharge for all patients on the 3rd post operative day. This study compares thirty consecutive discharges of unselected patients undergoing elective infra-renal aortic surgery following introduction of the pathway to the thirty consecutive cases preceding its introduction. Reasons for prolonged hospital stay were recorded.

RESULTS

Six of thirty patients achieved discharge by Day 3. The median hospital stay reduced from 9 (range 4 to 17 days) to 5 days (range 2 to 12 days) following introduction of the pathway. There was one readmission within 30 days and no complications attributable to the pathway implementation. Cardiac complications and home planning were the most common causes of delayed discharge.

CONCLUSION

Post-operative stay in patients undergoing standard elective open infra-renal aortic surgery can be safely reduced with the introduction of a goal directed pathway.

Fast-track surgery in laparoscopic radical prostatectomy: basic principles

Fast-track surgery describes innovative treatment concepts ensuring a faster convalescence phase. The aim of this study was to allow hospital discharge 3 days after surgery without additional complications in patients receiving LRPE for localized prostate cancer. Twenty-five patients each were randomized in the study groups to verify if a fast-track regimen could be transferred into clinical routine. The perioperative data, early complications, hospital stay as well as readmission rate were analyzed. The mean postoperative stay was 3.6 days in the fast-track group versus 6.7 days in the conventional group. The overall complications were significantly less in the fast-track procedure. The readmission rate was low and not significant. Patients receiving an LRPE benefit from a suitable fast-track concept. The postoperative hospital stay could be shortened nearly by half with a significantly decreased overall complication rate. Thus, fast-track concepts might contribute to saving resources in the long term. However, more evidence based on larger prospective trials is needed to achieve optimal quality of life for patients perioperatively.

Early oral nutrition after major upper gastrointestinal surgery: why not?

PURPOSE OF REVIEW

To examine the available documentation addressing the introduction of early food after major upper gastrointestinal surgery.

RECENT FINDINGS

No high-quality trials, recent or old, have addressed this topic. A few attempts have been identified. Information is extracted from papers discussing other topics of postoperative care in this field. Generally, nasogastric tubes and nil-by-mouth prevail in the early postoperative period.

SUMMARY

The reluctance to allow early food at will is not evidence based, but neither is the safety of an alternative regimen. Early food at will should probably be allowed after hepatic resections, gastric resections, and total gastrectomies and maybe also after pancreaticoduodenectomies. Resections of the esophagus remain the most challenging issue. The need is urgent for high-powered and high-quality randomized controlled clinical trials.

Standardization of Perioperative Management: Clinical Pathways

Many initiatives have been introduced in the past decades to standardize and improve clinical perioperative care and thereby improve patient care. Clinical pathways (also known as integrated care pathways, critical pathways, critical paths, care paths) are structured multidisciplinary care plans that detail essential steps in the care of patients with a specific clinical problem. They are designed to support the implementation and translation of national guidelines into local protocols and their subsequent application to clinical practice. In surgery, clinical pathways are standardized protocols for the management of patients who have common conditions undergoing common surgical procedures.