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Wong MSH, Pons A, De Sousa P, Proli C, Jordan S, Begum S, Buderi S, Lim E. Assessing patient perception and preferences for outcomes in lung cancer resection surgery: a cross-sectional study. J Thorac Dis 2024; 16:3844-3853. [PMID: 38983144 PMCID: PMC11228752 DOI: 10.21037/jtd-23-1800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/17/2024] [Indexed: 07/11/2024]
Abstract
Background Surgical resection is the primary treatment for early-stage lung cancer, but little is known about the outcomes that truly matter to patients. This aim of our study was to identify the aspects of postoperative outcomes that matter most to patients undergoing lung cancer surgery and explore the influence of clinical and demographic factors on their importance ratings. Methods We performed a cross-sectional study of patients undergoing lung resection for non-small cell lung cancer at our institution from November 2021 to May 2022. Patients were surveyed using a self-developed questionnaire and the European Organisation for Research and Treatment of Cancer core health-related quality of life questionnaire (EORTC QLQ-C30) prior to surgery. Ordinal logistic regression was performed to determine associations between individual patient factors and outcome importance ratings. Results Forty patients completed the survey during the study period. Patients prioritized oncologic outcomes, with 95% rating R0 resection and cancer recurrence as "very important". Other important factors included overall survival (90%), postoperative complications (e.g., myocardial infarction: 92.5%, infection: 87.5%), and the need for reoperation (82.5%). Health-related quality of life factors, such as chronic pain (77.5%) and the ability to return to normal physical and exercise levels (75%), were also highly valued. Certain patient clinical and demographic factors demonstrated significant associations with importance placed on certain outcomes. Preoperative health-related quality of life scores did not influence outcome importance ratings. Conclusions This study provides insights into the outcomes that matter most to patients undergoing lung cancer surgery. Oncologic outcomes and postoperative complications were prioritized, while scar-related factors were less important. Patient preferences varied based on demographic and clinical factors. Understanding these preferences can enhance shared decision-making and improve patient-centered care in thoracic surgical oncology.
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Affiliation(s)
- Matthew Shiu Hang Wong
- Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Aina Pons
- Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Paulo De Sousa
- Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Chiara Proli
- Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Simon Jordan
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Sofina Begum
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Silviu Buderi
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Eric Lim
- Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
- Department of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
- Imperial College London, London, UK
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Palleiko BA, Singh A, Strader C, Patil T, Crawford A, Emmerick I, Lou F, Uy K, Maxfield MW. Clinical outcomes and staff satisfaction after adoption of digital chest drainage system for minimally invasive lung resections. J Thorac Dis 2024; 16:2963-2974. [PMID: 38883637 PMCID: PMC11170378 DOI: 10.21037/jtd-23-1747] [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: 11/16/2023] [Accepted: 03/22/2024] [Indexed: 06/18/2024]
Abstract
Background Digital chest drainage systems (DCDS) provide reliable pleural drainage while quantifying fluid output and air leak. However, the benefits of DCDS in the contemporary era of minimally invasive thoracic surgery and enhanced recovery after surgery (ERAS) protocols have not been fully investigated. Additionally, hospital and resident staff experiences after implementation of a DCDS have not been fully explored. The objective of this study was to evaluate the clinical outcomes and hospital staff experience after adoption of a DCDS for minimally invasive lung resections. Methods A single-center retrospective review of patients who underwent minimally invasive lung resection (lobectomy, segmentectomy, and wedge resection) and received a DCDS from 11/1/2021 to 11/1/2022. DCDS patients were compared to sequential historical controls (3/1/2019-6/30/2021) who received a analog chest drainage system. For the analog system, chest tubes were removed when no bubbles were observed in the water seal compartment with Valsalva, cough, and in variable positions. With a DCDS, chest tubes were removed when the air leak was less than 30 cc/min for 8 hours, with no spikes. All patients followed an institutional ERAS protocol. Primary outcomes were length of stay (LOS) and chest tube duration. Hospital staff and residents were surveyed regarding their experience. Results One hundred and twenty-four patients received DCDS, and 248 received an analog chest drainage system. There was a reduction in mean LOS (3.6 vs. 4.4 days, P=0.01) and chest tube duration (2.7 vs. 3.6 days, P=0.03) in the DCDS group. Hospital staff (n=77, 46% response rate) reported the DCDS easier to use (60%, P<0.001) and easier to care for patients with (65%, P<0.001) compared to the analog system. Surgical residents (n=28, 56% response rate) reported increased confidence in interpretation of air leak (75%, P<0.001) and decision-making surrounding chest tube removal (79%, P<0.001). Conclusions Using a DCDS can reduce LOS and chest tube duration in the contemporary setting of minimally invasive lung resections and ERAS protocols. Increased confidence of resident decision-making for chest tube removal may contribute to improved outcomes.
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Affiliation(s)
- Benjamin A Palleiko
- School of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anupama Singh
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Christopher Strader
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Tanmay Patil
- School of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Allison Crawford
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Isabel Emmerick
- Division of Thoracic Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Feiran Lou
- Division of Thoracic Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Karl Uy
- Division of Thoracic Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Mark W Maxfield
- Division of Thoracic Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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3
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Goldblatt JG, Bibo L, Crawford L. Does Enhanced Recovery After Surgery Protocols Reduce Complications and Length of Stay After Thoracic Surgery: A Systematic Review of the Literature. Cureus 2024; 16:e59918. [PMID: 38854276 PMCID: PMC11161212 DOI: 10.7759/cureus.59918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Enhanced recovery after surgery (ERAS) has an increasingly important role in the perioperative management of thoracic surgical patients. It has been extensively studied in multiple surgical specialties, particularly colorectal surgery, where ERAS protocols have been shown to reduce postoperative length of stay and postoperative complications. Electronic searches of two research databases were performed: PubMed (1972 to October 2023) and Ovid MEDLINE (1946 to October 2023). The literature search was completed on January 4, 2024. Search terms included: "thoracic surgery" and "ERAS" or "Enhanced Recovery After Surgery". The search was limited to studies evaluating humans undergoing thoracic surgery for any indication. The primary outcome was overall morbidity, with secondary outcomes including mortality, length of stay, and pulmonary complications. The search yielded a total of 794 records, of which 30 (four meta-analyses and 26 observational trials) met the relevant inclusion and exclusion criteria. This review suggested the implementation of ERAS protocols can lead to a reduction in postoperative morbidity; however, this was not a consistent finding. The majority of studies included demonstrated a reduction in the length of stay with the implementation of ERAS. Overall, ERAS/ERATS is an important adjunct to the management of patients requiring thoracic surgery, consistently leading to shorter lengths of stay and likely contributing to reduced rates of postoperative morbidity. Further research will be required to determine the impact of the recently released ERATS guidelines.
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Affiliation(s)
| | - Liam Bibo
- Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, AUS
| | - Lachlan Crawford
- Cardiothoracic Surgery, Princess Alexandra Hospital, Brisbane, AUS
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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5
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Forster C, Jacques V, Abdelnour-Berchtold E, Krueger T, Perentes JY, Zellweger M, Gonzalez M. Enhanced recovery after chest wall resection and reconstruction: a clinical practice review. J Thorac Dis 2024; 16:2604-2612. [PMID: 38738262 PMCID: PMC11087605 DOI: 10.21037/jtd-23-911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/29/2024] [Indexed: 05/14/2024]
Abstract
Since the late 1990s, and Henrik Kehlet's hypothesis that a reduction of the body's stress response to major surgeries could decrease postoperative morbidity, "Enhanced Recovery After Surgery" (ERAS) care pathways have been streamlined. They are now well accepted and considered standard in many surgical disciplines. Yet, to this day, there is no specific ERAS protocol for chest wall resections (CWRs), the removal of a full-thickness portion of the chest wall, including muscle, bone and possibly skin. This is most unfortunate because these are high-risk surgeries, which carry high morbidity rates. In this review, we propose an overview of the current key elements of the ERAS guidelines for thoracic surgery that might apply to CWRs. A successful ERAS pathway for CWR patients would entail, as is the standard approach, three parts: pre-, peri- and postoperative elements. Preoperative items would include specific information, targeted patient education, involvement of all members of the team, including the plastic surgeons, smoking cessation, dedicated nutrition and carbohydrate loading. Perioperative items would likely be standard for thoracotomy patients, namely carefully selective pre-anesthesia sedative medication only in some rare instances, low-molecular-weight heparin throughout, antibiotic prophylaxis, minimization of postoperative nausea and vomiting, avoidance of fluid overload and of urinary drainage. Postoperative elements would include early mobilization and feeding, swift discontinuation of intravenous fluid supply and chest tube removal as soon as safe. Optimal pain management throughout also appears to be critical to minimize the risk of respiratory complications. Together, all these items are achievable and may hold the key to successful introduction of ERAS pathways to the benefit of CWR patients.
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Affiliation(s)
- Céline Forster
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Valentin Jacques
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Thorsten Krueger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jean Yannis Perentes
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Matthieu Zellweger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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6
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Mathew DM, Khusid E, Lui B, Weber M, Boyer R, White RS, Walsh S. Gaps in literature on enhanced recovery after thoracic surgery: Considering social determinants of health. Am J Surg 2024; 230:111-114. [PMID: 38052670 DOI: 10.1016/j.amjsurg.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/18/2023] [Accepted: 11/26/2023] [Indexed: 12/07/2023]
Affiliation(s)
| | - Elizabeth Khusid
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Marissa Weber
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Richard Boyer
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
| | - Spencer Walsh
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
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7
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Davey MG, Donlon NE, Fearon NM, Heneghan HM, Conneely JB. Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials. Obes Surg 2024; 34:778-789. [PMID: 38273146 PMCID: PMC10899423 DOI: 10.1007/s11695-024-07072-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery. AIM To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC). METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC. CONCLUSION ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Noel E Donlon
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Naomi M Fearon
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Helen M Heneghan
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - John B Conneely
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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8
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Yamanaka T, Sakairi Y, Sata Y, Toyoda T, Inage T, Tanaka K, Suzuki H, Matsui Y, Yoshino I. What are the risk factors for postoperative home oxygen therapy in patients with lung cancer? J Thorac Dis 2024; 16:989-996. [PMID: 38505039 PMCID: PMC10944715 DOI: 10.21037/jtd-23-1539] [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: 10/03/2023] [Accepted: 12/15/2023] [Indexed: 03/21/2024]
Abstract
Background Home oxygen therapy (HOT) is used to treat chronic respiratory diseases and is sometimes required in patients with lung cancer after radical surgery. We aimed to identify the risk factors for postoperative home-based oxygen therapy in patients with lung cancer. Methods Patients who underwent surgery for primary lung cancer at Chiba University Hospital between January 2019 and March 2021 were included. Patients who did not undergo complete resection, died in hospital after surgery, or used oxygen therapy preoperatively were excluded. Eligible patients were divided into HOT and non-HOT groups. They were retrospectively analyzed for risk factors for postoperative HOT using medical records in a multivariate analysis. Results A total of 410 patients were included in this study, 24 (5.9%) of whom required HOT after surgery. The HOT group comprised significantly more men, heavy smokers, and patients with pulmonary comorbidities, low percent forced expiratory volume, percent forced vital capacity, predicted postoperative forced expiratory volume in 1 s, and postoperative pulmonary complications on univariate analysis. In a multivariate analysis, independent risk factors for postoperative HOT were pulmonary comorbidities [odds ratio (OR): 5.94; 95% confidence interval (CI): 1.64-21.5; P=0.002) and postoperative pulmonary complications (OR: 5.39; 95% CI: 2.14-13.5; P<0.001). The postoperative HOT application rate was calculated according to a formula developed for this purpose. Conclusions Comorbid pulmonary diseases and postoperative pulmonary complications were significantly associated with postoperative HOT in patients with lung cancer.
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Affiliation(s)
- Takahiro Yamanaka
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuichi Sakairi
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuki Sata
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takahide Toyoda
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Terunaga Inage
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuhisa Tanaka
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hidemi Suzuki
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yukiko Matsui
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
- Thoracic Surgery, School of Medicine International University of Health and Welfare, Narita, Japan
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9
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Fryer ML, Palleiko BA, Emmerick I, Crawford A, Kadiyala M, Lou F, Uy K, Maxfield MW. Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection. J Thorac Dis 2024; 16:1324-1337. [PMID: 38505051 PMCID: PMC10944727 DOI: 10.21037/jtd-23-1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/12/2024] [Indexed: 03/21/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections. Methods Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database. Results We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups. Conclusions The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.
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Affiliation(s)
- Madeline L. Fryer
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | | | - Isabel Emmerick
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Allison Crawford
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Mamatha Kadiyala
- Department of Anesthesiology, UMass Chan Medical School, Worcester, MA, USA
| | - Feiran Lou
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Karl Uy
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
| | - Mark W. Maxfield
- Department of Surgery, UMass Chan Medical School, Worcester, MA, USA
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Clet A, Guy M, Muir JF, Cuvelier A, Gravier FE, Bonnevie T. Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study. Healthcare (Basel) 2024; 12:436. [PMID: 38391811 PMCID: PMC10887527 DOI: 10.3390/healthcare12040436] [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: 11/21/2023] [Revised: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.
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Affiliation(s)
- Augustin Clet
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Marin Guy
- Centre Aquitain Du Dos, Hôpital Privé Saint-Martin, F-33600 Pessac, France
| | - Jean-François Muir
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Antoine Cuvelier
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Francis-Edouard Gravier
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Tristan Bonnevie
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
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11
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Perry TE. Emerging principles and practices in enhanced recovery after thoracic surgery. Curr Opin Anaesthesiol 2024; 37:55-57. [PMID: 38111194 DOI: 10.1097/aco.0000000000001329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
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12
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Bou-Samra P, Kneuertz PJ. Advances in the clinical use of patient-reported outcomes in thoracic surgery. Curr Opin Anaesthesiol 2024; 37:75-78. [PMID: 38085875 DOI: 10.1097/aco.0000000000001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW Patient-reported outcomes (PROs) are increasingly recognized as a clinical tool for measuring and improving patient-centric care. This review provides a summary on recent advances in the use of PROs in the field of thoracic surgery. RECENT FINDINGS PROs have been used as primary endpoints in clinical trials and observational studies evaluating clinical care pathways and quantifying the benefits of minimally invasive surgical techniques for patients undergoing lung surgery. Qualitative and quantitative research has yielded fundamental insights into which PRO domains are meaningful and valued by patients after lung surgery. Patient experience and recovery after esophagectomy have been further characterized by using PROs. New disease-specific survey tools for patients have been developed to track long-term symptoms after esophageal reconstruction. Patient satisfaction has emerged as the key metric used to gauge the patient centeredness of hospital systems. SUMMARY Advances have been made in the application of PROs in multiple areas of thoracic surgery, which include lung and esophageal surgery. The growing focus on the use of PROs in clinical pathways has led to a better understanding on how to optimize patient experience.
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Affiliation(s)
- Patrick Bou-Samra
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center
| | - Peter J Kneuertz
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center
- Ohio State University Comprehensive Cancer Center- James and Solove Research Institute, Columbus, Ohio, USA
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Hsiao WL, Wu YC, Tai HC. Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery. Sci Rep 2024; 14:302. [PMID: 38167861 PMCID: PMC10762210 DOI: 10.1038/s41598-023-50881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.
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Affiliation(s)
- Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Cheng Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan
| | - Hao-Chih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan.
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Wang Y, Luo S, Wang S. Evaluation of enhanced recovery after surgery for gastric cancer patients undergoing gastrectomy: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne 2023; 18:551-564. [PMID: 38239576 PMCID: PMC10793142 DOI: 10.5114/wiitm.2023.131723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 01/22/2024] Open
Abstract
Introduction For complicated surgical patients, enhanced recovery after surgery (ERAS) decreases stress and hospital stays. It accelerates recovery and lowers readmissions, morbidity, and death. ERAS's effectiveness in stomach cancer laparoscopic-assisted gastrectomy (LAG) or robotic gastrectomy is still debated. Aim This study assesses the efficacy and safety of the ERAS program for patients undergoing gastrectomy for gastric cancer. Material and methods PRISMA-compliant searches were performed in Medline, Embase, PubMed, the Web of Sciences, and the Cochrane Library databases until March 2023. The search included articles that compared ERAS protocol results for gastric cancer surgery patients to conventional care. RevMan performed meta-analysis, and the Cochrane Risk of Bias Assessment Tool assessed study quality. Results This meta-analysis contained 11 carefully chosen randomized controlled trials (RCTs) involving 1790 people. The ERAS group had 902 participants, while the traditional care group had 888. The ERAS group had a shorter post-operative hospital stay, with a weighted mean difference (WMD) of -1.12 days (95% CI: -1.89 to -0.35, p = 0.00001), I2 = 89%, and a lower number of patients with post-operative problems, with an odds ratio (OR) of 0.73 (95% CI: 0.55 to 0.97; p = 0.03), I2 = 60%. Conclusions The ERAS procedure has been shown to be effective as well as beneficial for patients undergoing either laparoscopic-assisted or robotic gastrectomy for gastric cancer, since it lowers post-operative complications and accelerates recovery with improved results.
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Affiliation(s)
- Ying Wang
- Department of General Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Shengrui Luo
- Department of Gastrointestinal Surgery, Qujing, Second People’s Hospital of Yunnan Province, Qujing, China
| | - Shanshan Wang
- Department of Hepatobiliary Surgery, The People’s Hospital of Longhua, Shenzhen, China
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Chen K, Yang D, Li F, Gao L, Tian Y, Xu B, Xu X, Xu Q, Cao J. Changes in the symptom clusters of elderly patients with lung cancer over the course of postoperative rehabilitation and their correlation with frailty and quality of life: A longitudinal study. Eur J Oncol Nurs 2023; 67:102388. [PMID: 37948789 DOI: 10.1016/j.ejon.2023.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To explore changes in the symptom clusters of perioperatively elderly patients with lung cancer at different time points (i.e., the day of admission [T0]), 2-4 days after surgery [T1], 1 month after discharge [T2] and 3 months after discharge [T3]) and to analyze correlations between cluster severity, frailty and quality of life (QOL). METHODS A longitudinal study was conducted from August 2020 to June 2021 among elderly lung cancer patients undergoing surgery at hospitals in Jiangsu Province. Data were collected using the Chinese Tilburg Frailty Indicator, the MD Anderson Symptom Inventory and the Quality of Life-Core scale. RESULTS According to exploratory factor analysis, a total of 5 symptom clusters were found and three of them (the global mental function symptom cluster, the special mental function symptom cluster and the respiratory function symptom cluster) were persistent. The incidence of the top four symptoms varied at different time points. The severity of symptom clusters at different time points was positively correlated with frailty and negatively correlated with QOL. CONCLUSIONS The findings may serve as a reference for medical staff to implement symptom management in elderly lung cancer patients after surgery. Frailty may be an important variable affecting the severity of symptom clusters and the QOL of patients.
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Patel YS, Sullivan KA, Churchill IF, Beauchamp MK, Wald J, Mbuagbaw L, Fahim C, Hanna WC. Preconditioning program reduces the incidence of prolonged hospital stay after lung cancer surgery: Results from the Move For Surgery randomized clinical trial. Br J Surg 2023; 110:1467-1472. [PMID: 37643916 DOI: 10.1093/bjs/znad252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/30/2023] [Accepted: 07/23/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Lung cancer resection is associated with high rates of prolonged hospital stay. It is presumed that preconditioning with aerobic exercise can shorten the postoperative duration of hospital stay, but this has not yet been demonstrated in trials after lung cancer surgery. The aim of this study was to perform a RCT to determine whether Move For Surgery (MFS), a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, is associated with a lower incidence of prolonged hospital stay when compared to usual preoperative care. METHODS Patients undergoing lung resection for early-stage non-small cell lung cancer were enrolled before surgery into this blinded, single-site RCT, and randomized to either the MFS or control group in a 1 : 1 ratio. Patients in the MFS group were given a wearable activity tracker, and education about deep breathing exercises, nutrition, sleep hygiene, and smoking cessation. Participants were motivated/encouraged to reach incrementally increasing fitness goals remotely. Patients in the control group received usual preoperative care. The primary outcome was the difference in proportion of patients with hospital stay lasting more than 5 days between the MFS and control groups. RESULTS Of 117 patients screened, 102 (87.2 per cent) were eligible, enrolled, and randomized (51 per trial arm). The majority (95 of 102, 93.1 per cent) completed the trial. Mean(s.d.) age was 67.2(8.8) years and there were 55 women (58 per cent). Type of surgery and rates of thoracotomy were not different between arms. The proportion of patients with duration of hospital stay over 5 days was 3 of 45 (7 per cent) in the MFS arm compared to 12 of 50 (24 per cent) in the control arm (P = 0.021). CONCLUSION MFS, a home-based and wearable technology-enhanced preconditioning program before lung cancer surgery, decreased the proportion of patients with a prolonged hospital stay. Registration number: NCT03689634 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Yogita S Patel
- Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kerrie A Sullivan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Isabella F Churchill
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marla K Beauchamp
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Joshua Wald
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Christine Fahim
- Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Waël C Hanna
- Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Laohathai S, Sadad Z, Suvarnakich K, Pathonsamit C, Tantraworasin A. Efficacy of the Enhanced Recovery After Surgery program for thoracic surgery in a developing country. Indian J Thorac Cardiovasc Surg 2023; 39:476-483. [PMID: 37609619 PMCID: PMC10441865 DOI: 10.1007/s12055-023-01518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 08/24/2023] Open
Abstract
Purpose Enhanced Recovery After Surgery (ERAS) is a strategy used to improve perioperative outcomes and reduce complications. However, data on the efficacy of ERAS in thoracic surgery in developing countries are limited. The current study aimed to validate the benefits of ERAS among patients at a single institution. Methods This was a retrospective study of patients who underwent pulmonary resection at Vajira Hospital, Bangkok, Thailand, between 2016 and 2020. To compare outcomes, patients were divided into the pre-ERAS group (2016-2018) and the post-ERAS group (2019-2020) using propensity score matching (1:2) with the year 2019 as the cutoff for introducing ERAS protocols at our institution. Results In total, 321 patients were included in the analysis (pre-ERAS group, n = 74; post-ERAS group, n = 247). After propensity score matching, 56 and 112 patients were classified under the pre- and post-ERAS groups, respectively. The post-ERAS group had significantly lower pain scores than the pre-ERAS group on postoperative days 1, 2, and 3, and a lower volume of intraoperative blood loss. In the multivariable analysis, the post-ERAS group had a shorter chest tube duration (mean difference = -1.62 days, 95% confidence interval = -2.65 to -0.31) and length of hospital stay (mean difference = -2.40 days, 95% confidence interval = -4.45 to -0.65) than the pre-ERAS group. Conclusion The use of ERAS guidelines in pulmonary resection is beneficial. Although no significant differences were observed in postoperative complication rate, intensive care unit stay, and additional cost burden between the two groups, patients in the post-ERAS group had a shorter postoperative chest tube duration, shorter hospital stays, shorter operative time, lower postoperative pain score, and lower volume of intraoperative blood loss.
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Affiliation(s)
- Sira Laohathai
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Zarina Sadad
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kanok Suvarnakich
- Cardiothoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chompunoot Pathonsamit
- Department of Anaesthesia, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Apichat Tantraworasin
- Clinical Surgical Research Centre, Faculty of Medicine, Chiang Mai University, 110 Intrawaroros Road, Chiang Mai, Thailand
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ma H, Li X, Wang Z, Qiao Q, Gao Y, Yuan H, Guan B, Guan Z. The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study. Perioper Med (Lond) 2023; 12:33. [PMID: 37430359 DOI: 10.1186/s13741-023-00327-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND To investigate the effect of intraoperative goal-directed fluid therapy (GDFT) combined with enhanced recovery after surgery (ERAS) program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection. METHODS Patients, more than 60 years old, undergoing thoracoscopic pulmonary resection for non-small cell lung cancer were randomly divided into GDFT group and restrictive fluid therapy (RFT) group. ERAS program was implemented in all patients. In GDFT group, the intraoperative fluid management was guided by stroke volume variation (SVV), cardiac index (CI), and mean arterial pressure (MAP) and maintained the SVV < 13%, CI > 2.5 L/min/m2, and MAP > 65 mmHg. In RFT group, fluid maintenance with 2 ml/kg/h of balanced crystalloid solution, norepinephrine was used to maintain MAP > 65 mmHg. The incidence of postoperative acute kidney injury (AKI) and pulmonary and cardiac complications was compared. RESULTS Two-hundred seventy-six patients were enrolled and randomly divided into two groups (138 in each group). Compared to RFT group, the total intraoperative infusion volume, colloids infusion volume, and urine output were more; the dosage of norepinephrine was lower in GDFT group. Although there were no significant differences of postoperative AKI (GDFT vs RFT; 4.3% vs 8%; P = 0.317) and composite postoperative complications (GDFT vs RFT; 66 vs 70) between groups, but the postoperative increase degree of serum creatinine was lower in GDFT group than that in RFT group (GDFT vs RFT; 91.9 ± 25.2 μmol/L vs 97.1 ± 17.6 μmol/L; P = 0.048). CONCLUSIONS Under ERAS program, there was no significant difference of AKI incidence between GDFT and RFT in elderly patients undergoing thoracoscopic pulmonary resection. But postoperative increase degree of serum creatinine was lower in GDFT group. TRIAL REGISTRATION Registered at ClinicalTrials.gov, NCT04302467 on 26 February 2020.
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Affiliation(s)
- Hongmei Ma
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Department of Anesthesiology, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Xin Li
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhe Wang
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qiao Qiao
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yanfeng Gao
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hui Yuan
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bin Guan
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zheng Guan
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Zhou Y, Li R, Liu Z, Qi W, Lv G, Zhong M, Liu X, Zhu M, Jiang Z, Chen S, Shi B, Zhu Y. The effect of the enhanced recovery after surgery program on radical cystectomy: a meta-analysis and systematic review. Front Surg 2023; 10:1101098. [PMID: 37273829 PMCID: PMC10235530 DOI: 10.3389/fsurg.2023.1101098] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/20/2023] [Indexed: 06/06/2023] Open
Abstract
Background Bladder cancer is the ninth most common malignant tumor worldwide. As an effective evidence-based multidisciplinary protocol, the enhanced recovery after surgery (ERAS) program is practiced in many surgical disciplines. However, the function of ERAS after radical cystectomy remains controversial. This systematic review and meta-analysis aims to research the impact of ERAS on radical cystectomy. Methods A systematic literature search on PubMed, EMBASE, SCOPUS, and the Cochrane Library databases was conducted in April 2022 to identify the studies that performed the ERAS program in radical cystectomy. Studies were selected, data extraction was performed independently by two reviewers, and quality was assessed using a random effects model to calculate the overall effect size. The odds ratio and standardized mean difference (SMD) with a 95% confidence interval (CI) served as the summary statistics for the meta-analysis. A sensitivity analysis was subsequently performed. Results A total of 25 studies with 4,083 patients were enrolled. The meta-analysis showed that the complications (OR = 0.76; 95% CI: 0.63-0.90), transfusion rate (OR = 0.59; 95% CI: 0.39-0.90), readmission rate (OR = 0.79; 95% CI: 0.64-0.96), length of stay (SMD = -0.79; 95% CI: -1.41 to -0.17), and time to first flatus (SMD = -1.16; 95% CI: -1.58 to -0.74) were significantly reduced in the ERAS group. However, no significance was found in 90-day mortality and urine leakage. Conclusion The ERAS program for radical cystectomy can effectively decrease the risk of overall complications, postoperative ileus, readmission rate, transfusion rate, length of stay, and time to first flatus in patients who underwent radical cystectomy with relative safety. Systematic Review Registration https://inplasy.com/, identifier INPLASY202250075.
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Affiliation(s)
- Yongheng Zhou
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zhifeng Liu
- Department of Urology Surgery, Taian City Central Hospital, Taian, China
| | - Wenqiang Qi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Guangda Lv
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Minglei Zhong
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Xigao Liu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Meikai Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Zhiwen Jiang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Shouzhen Chen
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Yaofeng Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
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Galkin VN, Esakov YS, Samsonik SA, Regushevskaya DV, Banova ZI, Giverts IY. [Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]. Khirurgiia (Mosk) 2023:88-97. [PMID: 37916562 DOI: 10.17116/hirurgia202310188] [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: 11/03/2023]
Abstract
OBJECTIVE To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer. MATERIAL AND METHODS A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections). RESULTS Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively. CONCLUSION Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.
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Affiliation(s)
- V N Galkin
- Moscow City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - Yu S Esakov
- Moscow City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - S A Samsonik
- Moscow City Clinical Oncology Hospital No. 1, Moscow, Russia
| | | | - Zh I Banova
- Moscow City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - I Yu Giverts
- Pirogov Moscow City Clinical Hospital No. 1, Moscow, Russia
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Boisen ML, Fernando RJ, Alfaras-Melainis K, Hoffmann PJ, Kolarczyk LM, Teeter E, Schisler T, Ritchie PJ, La Colla L, Rao VK, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2021. J Cardiothorac Vasc Anesth 2022; 36:4252-4265. [PMID: 36220681 DOI: 10.1053/j.jvca.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Paul J Hoffmann
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Emily Teeter
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Travis Schisler
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter J Ritchie
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Luca La Colla
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Theresa A Gelzinis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA.
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Andreas MN, Dziodzio T, Hillebrandt KH, Elsner A, Strauchmann J, Aydin M, Pratschke J, Rückert JC, Neudecker J. Aktuelle ERAS-Implementierung in der Thoraxchirurgie an deutschen Kliniken. Zentralbl Chir 2022; 147:S21-S28. [DOI: 10.1055/a-1759-4375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Einleitung In den letzten Jahren haben sich zunehmend ERAS-Behandlungspfade in vielen chirurgischen Bereichen etabliert, da sie allgemeine Komplikationen reduzieren und die Genesung
von Patienten erheblich beschleunigen können. Für die Thoraxchirurgie wurden 2019 erstmals ERAS-Guidelines von der ERAS Society in Zusammenarbeit mit der European Society of Thoracic
Surgeons (ESTS) veröffentlicht. Inwieweit sich ERAS-Maßnahmen im klinischen Alltag in der Thoraxchirurgie in Deutschland etabliert haben, wurde anhand eines Online-Fragebogens evaluiert.
Material und Methoden Es wurde eine Onlineumfrage zur aktuellen ERAS-Implementierung an deutschen Kliniken durchgeführt. Zeitraum der Umfrage war vom 12.05.2021 bis zum 01.06.2021.
Im Fragebogen, der 22 Fragen umfasste, wurde die aktuelle Umsetzung verschiedener perioperativer Maßnahmen (u. a. Mobilisation, Thoraxdrainagen-Management, Schmerzmanagement) als wesentliche
Items des ERAS-Pathways erfragt. Anschließend wurden die Resultate zusammengefasst, beschreibend analysiert und in den Kontext der aktuellen Literatur gesetzt.
Ergebnisse Von 155 angeschriebenen leitenden Thoraxchirurgen beantworteten 32 den Fragebogen. Bei 28,1% (n = 9) der Kliniken war ein ERAS-Kernteam etabliert, eine Datenbank zur
Erfassung der ERAS-Items gab es in 15,6% (n = 5). Zudem bekamen die Patienten meist kein ERAS-Tagebuch (96,9%, n = 31) ausgehändigt. Ein präoperatives Carboloading wurde von 15,6% (n = 5)
durchgeführt. Eine PONV-Prophylaxe wurde bei 59,4% (n = 19) der Befragten standardmäßig durchgeführt. In der Regel wurde bei elektiven anatomischen Resektionen eine Thoraxdrainage (84,4%,
n = 27) eingelegt. Bei 3% (n = 1) der Zentren wurden 2 Drainagen eingelegt, bei 12,5% (n = 4) wurde keine Drainage intraoperativ eingebracht. Meist wurden digitale Drainagesysteme verwendet
(90,6%, n = 29). Der am häufigsten angewendete initiale Drainagensog war –10 cm H2O (75%, n = 24). Einen Sog von ≤ 2 cmH2O verwendeten lediglich 2 Befragte. Die
Drainageentfernung erfolgte in 50% (n = 16) der Fälle am 1. oder 2. postoperativen Tag (POD), in 34,4% (n = 11) am 3. und 4. POD und bei 9,4% (n = 3) verblieb die Drainage über den 4. Tag
hinaus. Bei 71,9% (n = 23) der Befragten erfolgte die erste Mobilisation postoperativ noch am OP-Tag.
Diskussion Die Implementierung der ERAS-Guidelines ist in Deutschland interindividuell noch sehr variabel. Bestimmte perioperative Prozesse werden bereits gut abgedeckt, allerdings
ist eine vollständige Umsetzung von ERAS-Items noch nicht gänzlich in der klinischen Praxis angekommen. Erste Schritte in diese Richtung wurden bereits gemacht und legen die Grundlage für
eine weitere zentrumsübergreifende Zusammenarbeit.
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Affiliation(s)
- Marco Nicolas Andreas
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Tomasz Dziodzio
- Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Deutschland
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Karl-Herbert Hillebrandt
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
- BIH Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Deutschland
| | - Aron Elsner
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Julia Strauchmann
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Mustafa Aydin
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jens-Carsten Rückert
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jens Neudecker
- Chirurgische Klinik, Thoraxchirurgie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
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Li R, Qiu J, Qu C, Ma Z, Wang K, Zhang Y, Yue W, Tian H. Comparison of perioperative outcomes with or without routine chest tube drainage after video-assisted thoracoscopic pulmonary resection: A systematic review and meta-analysis. Front Oncol 2022; 12:915020. [PMID: 36003771 PMCID: PMC9393739 DOI: 10.3389/fonc.2022.915020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn recent years, an increasing number of thoracic surgeons have attempted to apply no routine chest tube drainage (NT) strategy after thoracoscopic lung resection. However, the safety and feasibility of not routinely placing a chest tube after lung resection remain controversial. This study aimed to investigate the effect of NT strategy after thoracoscopic pulmonary resection on perioperative outcomes.MethodsA comprehensive literature search of PubMed, Embase, and the Cochrane Library databases until 3 January 2022 was performed to identify the studies that implemented NT strategy after thoracoscopic pulmonary resection. Perioperative outcomes were extracted by 2 reviewers independently and then synthesized using a random-effects model. Risk ratio (RR) and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed.ResultsA total of 12 studies with 1,381 patients were included. The meta-analysis indicated that patients in the NT group had a significantly reduced postoperative length of stay (LOS) (SMD = -0.91; 95% CI: -1.20 to -0.61; P < 0.001) and pain score on postoperative day (POD) 1 (SMD = -0.95; 95% CI: -1.54 to -0.36; P = 0.002), POD 2 (SMD = -0.37; 95% CI: -0.63 to -0.11; P = 0.005), and POD 3 (SMD = -0.39; 95% CI: -0.71 to -0.06; P = 0.02). Further subgroup analysis showed that the difference of postoperative LOS became statistically insignificant in the lobectomy or segmentectomy subgroup (SMD = -0.30; 95% CI: -0.91 to 0.32; P = 0.34). Although the risk of pneumothorax was significantly higher in the NT group (RR = 1.75; 95% CI: 1.14–2.68; P = 0.01), the reintervention rates were comparable between groups (RR = 1.04; 95% CI: 0.48–2.25; P = 0.92). No significant difference was found in pleural effusion, subcutaneous emphysema, operation time, pain score on POD 7, and wound healing satisfactory (all P > 0.05). The sensitivity analysis suggested that the results of the meta-analysis were stabilized.ConclusionsThis meta-analysis suggested that NT strategy is safe and feasible for selected patients scheduled for video-assisted thoracoscopic pulmonary resection.Systematic Review Registrationhttps://inplasy.com/inplasy-2022-4-0026, identifier INPLASY202240026.
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Xu H, Guo R, Yang Y. Effects of Osimertinib Combined With Pulmonary Rehabilitation and Health Care Training on Pulmonary Function, Complications, and Quality of Life in Patients After Radical Resection of Lung Cancer. Front Public Health 2022; 10:911377. [PMID: 35757653 PMCID: PMC9226408 DOI: 10.3389/fpubh.2022.911377] [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: 04/02/2022] [Accepted: 04/22/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To explore the effects of osimertinib combined with pulmonary rehabilitation and health care training on pulmonary function, complications, and the quality of life (QOL) in patients after radical resection of lung cancer. Methods The data of 120 patients with radical resection of lung cancer admitted to The First Affiliated Hospital of Zhengzhou University from February 2020 to February 2021 were retrospectively analyzed. According to the order of admission, they were equally divided into group p and group q. All patients were given pulmonary rehabilitation and health care training, and group p was treated with osimertinib, while group q received the treatment of pemetrexed combined with cisplatin. The pulmonary function, the incidence of complications, and QOL between the two groups were compared. Results Compared with group q, the pulmonary function was higher (P < 0.001), the incidence of complications was significantly lower (P < 0.05), and QOL scores were markedly higher in group p after treatment (P < 0.001). Conclusion The combination of osimertinib and pulmonary rehabilitation and health care training can improve the pulmonary function of patients with non-small cell lung cancer (NSCLC) with radical resection of lung cancer, and reduce their postoperative morbidity, thereby improving their QOL, which is conducive to reducing the patient's and society's medical burden.
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Affiliation(s)
- Haijiang Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruixia Guo
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yantao Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Zhang W, Zhang Y, Qin Y, Shi J. Outcomes of enhanced recovery after surgery in lung cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022; 9:100110. [PMID: 36158708 PMCID: PMC9500517 DOI: 10.1016/j.apjon.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/13/2022] [Indexed: 11/02/2022] Open
Abstract
Objective Methods Results Conclusions
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Liu J, Gao C, Fu H, Zhou X, Zhang L, Tang X, Wu Y, Zhu H, Yang S, Qu Y, Yang Y, Yang H. Implementation of multi-mode nursing insulation program for patients receiving surgery for spine tumor: a propensity score-matched analysis. BMC Surg 2022; 22:8. [PMID: 34996399 PMCID: PMC8742400 DOI: 10.1186/s12893-021-01463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spinal tumor surgery usually involved long operation time, large area of soft tissue resection and long wound, and was prone to hypothermia during the operation. Therefore, actively promoting insulation and optimizing the intraoperative insulation program have great potential in reducing the incidence of hypothermia and reducing the incidence of postoperative complications. In this study, we compared patients who did not implement multi-mode nursing insulation program (MNIP) with those who implemented MNIP, observing and comparing clinical outcomes, and complications in both groups, with the aim of developing an optimal management plan for the preoperative, intraoperative, and postoperative periods, respectively. METHODS We selected 2 periods of 1 year, before (n = 120 patients) and after MINP implementation (n = 120 patients). Data were collected on patient demographics, operative, perioperative details, temperature changes, anesthesia recovery effect, incidence of postoperative wound infection, length of hospital stay and complications. PS analyses were used for dealing with confounding bias in this retrospective observational study. RESULTS After PS matching, the outcomes of 120 well-balanced pairs of patients were compared (No-MNIP vs MNIP). There was no significant difference concerning the satisfaction survey. The results indicated that the MNIP had better insulation effect at 90 min, 120 min, 150 min after anesthesia induction and after surgery. There were 16 cases of complications in the No-MNIP group and 5 cases in the MNIP group postoperative, which have significant statistical difference. CONCLUSION In this study, the incidence of intraoperative hypothermia was effectively reduced by adopting the multi-mode insulation scheme, thus reducing the incidence of incision infection and shortening the length of hospital stay of patients.
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Affiliation(s)
- Juan Liu
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China.
| | - Chunyan Gao
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Hailong Fu
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Xiaonan Zhou
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Li Zhang
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Xiaomei Tang
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Yanru Wu
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Hui Zhu
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Sisi Yang
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Yafeng Qu
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Yajuan Yang
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
| | - Haiqin Yang
- Changzheng Hospital, Affiliated to Naval Military Medical University, Shanghai, China
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