Enhanced recovery after surgery (ERAS) programs for esophagectomy

Clinical and socioeconomic factors predicting return-to-work times after cholecystectomy

BACKGROUND

Cholecystectomy, a type of surgery commonly performed globally, has possible mutual effects on the socioeconomic conditions of different countries due to various postoperative recovery times.

AIMS

This study evaluated the medical and socioeconomic factors affecting delayed return-to-work (RTW) time after elective cholecystectomy.

METHODS

This retrospective study analysed patients who underwent elective cholecystectomy for benign gallbladder diseases from January 2022 to April 2023. The patients' medical and socioeconomic data were collected to investigate the clinical and socioeconomic factors correlated with RTW time of >30 days after surgery.

RESULTS

This study included 180 consecutive patients. Significant correlations were found between delayed RTW time (>30 days) and age (odds ratio [OR]: 1.059, 95% confidence interval [CI] 1.008-1.113, P = 0.024), lack of medical insurance (OR: 2.935, 95% CI 1.189-7.249, P = 0.02) and high-intensity labour jobs (OR: 3.649, 95% CI 1.495-8.909, P = 0.004). Patients without medical insurance (26.6 versus 18.9 days) and those with high-intensity labour jobs (23.9 versus 18.8 days) had a higher mean RTW time than those with insurance and a less-intense labour job (P < 0.001).

CONCLUSIONS

After cholecystectomy, older age, lack of medical insurance and high-intensity labour job were correlated with a delayed RTW time. Informing patients about their expected RTW time after surgery can help reduce costs.

Enhanced Recovery Protocol Versus Conventional Care in Patients Undergoing Esophagectomy for Cancer: Advantages in Clinical and Patient-Reported Outcomes

BACKGROUND

This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared.

METHODS

This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes.

RESULTS

Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group.

CONCLUSIONS

The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs.

Divergent Trends in Postoperative Length of Stay and Postdischarge Complications over Time

BACKGROUND

There is a push toward shorter length of stay (LOS) after surgery by hospitals, payers, and policymakers. However, the extent to which these changes have shifted the occurrence of complications to the postdischarge setting is unknown. The objectives of this study were to (1) evaluate changes in LOS and postdischarge complications over time and (2) assess factors associated with postdischarge complications.

STUDY DESIGN

Patients who underwent surgery across five specialties (colorectal, esophageal, hepatopancreatobiliary [HPB], gynecology, and urology) were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) procedure-targeted database (2014-2019). Trends in the proportion of postdischarge complications within 30 days of surgery and predictors of postdischarge complications were assessed using multivariable logistic regression.

RESULTS

Among 538,172 patients evaluated, median LOS decreased from 3 (2014) to 2 days (2019) (p < 0.001). Overall, 12.2% of patients experienced a 30-day complication, with 50.4% occurring postdischarge. with the highest in hysterectomy (80.9%), prostatectomy (74.6%), and cystectomy (54.6%). The overall postoperative complication decreased, but the proportion of postdischarge complications increased from 44.6% (2014) to 56.4% (2019) (p < 0.001), including surgical site infection (superficial/deep/organ space/wound dehiscence), other infection (pneumonia/urinary tract infection/sepsis), cardiovascular (myocardial infarction/cardiac arrest/stroke), and venous thromboembolism. Factors associated with an increased odds of postdischarge complications included Hispanic or other race, higher American Society of Anesthesiologists class, dependent functional status, increased body mass index, higher wound class, inpatient complication, longer operation, and procedure type (HPB/colorectal/hysterectomy/esophagectomy, vs. prostatectomy) (all p < 0.001).

CONCLUSION

This comprehensive retrospective analysis across five representative surgical specialties highlighted that although LOS has decreased over time, the proportion of postdischarge complications has increased over time. Focusing on the development of a comprehensive, proactive, postdischarge monitoring system to better identify and manage postdischarge complications is necessary.

Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes

BACKGROUND

Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy.

METHODS

A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies.

RESULTS

A total of 113 studies (n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature (n = 89, 79%), and cohort studies were the most common type of study design (n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases.

CONCLUSIONS

There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes

BACKGROUND

Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution.

METHODS

The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis.

RESULTS

The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01).

CONCLUSIONS

This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Combined and intraoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND

Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions.

AIM

To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness.

RESULTS

Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness.

CONCLUSION

Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Interventions targeting postoperative pulmonary complications (PPCs) in patients undergoing esophageal cancer surgery: a systematic review of randomized clinical trials and narrative discussion

Postoperative pulmonary complications (PPCs) represent the most common complications after esophageal cancer surgery. The lack of a uniform reporting nomenclature and a severity classification has hampered consistency of research in this area, including the study of interventions targeting prevention and treatment of PPCs. This systematic review focused on RCTs of clinical interventions used to minimize the impact of PPCs. Searches were conducted up to 08/02/2021 on MEDLINE (OVID), CINAHL, Embase, Web of Science, and the COCHRANE library for RCTs and reported in accordance with PRISMA guidelines. A total of 339 citations, with a pooled dataset of 1,369 patients and 14 RCTs, were included. Heterogeneity of study design and outcomes prevented meta-analysis. PPCs are multi-faceted and not fully understood with respect to etiology. The review highlights the paucity of high-quality evidence for best practice in the management of PPCs. Further research in the area of intraoperative interventions and early postoperative ERAS standards is required. A consistent uniform for definition of pneumonia after esophagectomy and the development of a severity scale appears warranted to inform further RCTs and guidelines.

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/Perioperative Quality Initiative (POQI) consensus statement on intraoperative and postoperative interventions to reduce pulmonary complications after oesophagectomy

BACKGROUND

Pulmonary complications are the most common morbidity after oesophagectomy, contributing to mortality and prolonged postoperative recovery, and have a negative impact on health-related quality of life. A variety of single or bundled interventions in the perioperative setting have been developed to reduce the incidence of pulmonary complications. Significant variation in practice exists across the UK. The aim of this modified Delphi consensus was to deliver clear evidence-based consensus recommendations regarding intraoperative and postoperative care that may reduce pulmonary complications after oesophagectomy.

METHODS

With input from a multidisciplinary group of 23 experts in the perioperative management of patients undergoing surgery for oesophageal cancer, a modified Delphi method was employed. Following an initial systematic review of relevant literature, a range of anaesthetic, surgical, and postoperative care interventions were identified. These were then discussed during a two-part virtual conference. Recommendation statements were drafted, refined, and agreed by all attendees. The level of evidence supporting each statement was considered.

RESULTS

Consensus was reached on 12 statements on topics including operative approach, pyloric drainage strategies, intraoperative fluid and ventilation strategies, perioperative analgesia, postoperative feeding plans, and physiotherapy interventions. Seven additional questions concerning the perioperative management of patients undergoing oesophagectomy were highlighted to guide future research.

CONCLUSION

Clear consensus recommendations regarding intraoperative and postoperative interventions that may reduce pulmonary complications after oesophagectomy are presented.

Perioperative statin medication impairs pulmonary outcome after abdomino-thoracic esophagectomy

Background

Although surgery is the curative option of choice for patients with locally advanced esophageal cancer, morbidity, especially the rate of pulmonary complications, and consequently mortality of patients undergoing abdomino-thoracic esophagectomy remain unacceptably high. Causes for developing post-esophagectomy pulmonary complications are trauma to the lung and thoracic cavity as well as systemic inflammatory response. Statins are known to influence inflammatory pathways, but whether perioperative statin medication impacts on inflammatory response and pulmonary complication development after esophagectomy had not been investigated, yet.

Methods

Retrospective analysis and propensity score matching of patients, who either received perioperative statin medication [statin( +)] or not [statin( −)], with regard to respiratory impairment (PaO₂/FiO₂ < 300 mmHg), pneumonia development, and inflammatory serum markers after abdomino-thoracic esophagectomy.

Results

Seventy-eight patients who underwent abdomino-thoracic esophagectomy for cancer were included into propensity score pair-matched analysis [statin( +): n = 26 and statin( −): n = 52]. Although no differences were seen in postoperative inflammatory serum markers, C-reactive protein values correlated significantly with the development of pneumonia beyond postoperative day 3 in statin( −) patients. This effect was attenuated under statin medication. No difference was seen in cumulative incidences of respiratory impairment; however, significantly higher rate (65.4% versus 38.5%, p = 0.0317, OR 3.022, 95% CI 1.165–7.892) and higher cumulative incidence (p = 0.0468) of postoperative pneumonia were seen in statin( +) patients, resulting in slightly longer postoperative stay on intensive care unit (p = 0.0612) as well as significantly prolonged postoperative in-hospital stay (p = 0.0185).

Conclusions

Development of pulmonary complications after abdomino-thoracic esophagectomy is multifactorial but frequent. The establishment of preventive measures into the perioperative clinical routine is mandatory for an improved patient outcome. Perioperative medication with statins might influence pneumonia development in the highly vulnerable lung after abdomino-thoracic esophagectomy. Perioperative interruption of statin medication might be beneficial in appropriate patients; however, further clinical trials and translational studies are needed to prove this hypothesis.

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair

BACKGROUND

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair.

METHODS

A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention.

RESULTS

Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective.

CONCLUSION

Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Preoperative Neutrophil to Lymphocyte Ratio Predicts Complications After Esophageal Resection That can be Used as Inclusion Criteria for Enhanced Recovery After Surgery

Background

The neutrophil to lymphocyte ratio (NLR) has been reported as an indicator for poor prognosis in many cancers including esophageal cancer. However, the relationship between the NLR and postoperative complications after esophageal cancer resection remains unclear. At present, enhanced recovery after surgery (ERAS) lacks inclusion criteria. The aim of this study is to determine whether the preoperative NLR (_preNLR) can predict complications after esophageal cancer resection, which could represent the criteria for ERAS.

Methods

This was a retrospective study on 171 patients who underwent esophagectomy at Hospital between November 2020 and November 2021(68 patients from Changhai Hospital, 65 patients from Shanghai General Hospital and 38 patients from Affiliated Hospital of Qingdao University). Univariate and multivariate logistic regression analyses were performed to demonstrate that the _preNLR could predict complications after esophagectomy.

Results

A _preNLR cutoff value of 2.30 was identified as having the greatest ability to predict complications with a sensitivity of 76% and specificity of 65%. Moreover, the Chi-squared test results showed that the _preNLR was significantly associated with complications (x²= 13.641, p < 0.001), and multivariate logistic regression analysis showed that body mass index (BMI), p stage and _preNLR were independent variables associated with the development of postoperative complications (p < 0.05).

Conclusion

The _preNLR can predict complications after esophagectomy, and these predicted complications can represent the criteria for recruiting patients for ERAS.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy

BACKGROUND

Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available.

METHODS

This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM.

RESULTS

The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy.

CONCLUSION

IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Spadework for Establishing Integrative Enhanced Recovery Program After Spine Surgery: Web-Based Survey Assessing Korean Medical Doctors’ Perspectives

Introduction

Efforts are necessary to promote postoperative patient management to reduce complications or side effects, particularly those adapted to spinal surgery. Considering compatible medical system in Korea, the study objective is to report the opinions of Korean medical doctors regarding integrative enhanced recovery after spine surgery.

Methods

From December 2020 to January 2021, members of the Korean Medical Association were asked to complete an online questionnaire regarding an integrative enhanced recovery program after spine surgery. A total of 726 participants responded to the survey.

Results

Approximately half of the respondents had more than 10 years of medical experience in the Korean health-care system, and 58.29% were affiliated with primary Korean medical clinics. The majority of respondents were not aware of the ERAS program (N = 412, 79.08%) but said that patient management would be advanced from the establishment of a postoperative medical program that reflected an integrated medical perspective (N = 505, 96.92%). Furthermore, Korean medical professionals believe that Korean medical interventions should play a major role in the pain management and digestive improvement sections of the upcoming postoperative program. Moreover, respondents claimed that Korean traditional medical modalities such as acupuncture, moxibustion, cupping, and herbal decoction should be included in the program.

Discussion/Conclusion

Responses collected from the present study can be used as a spadework for future studies. A study on the development of a comprehensive postoperative program that reflects the perspectives of patients and conventional medical doctors is needed.

Effect of Patient-Controlled Epidural Analgesia (PCEA) Based on ERAS on Postoperative Recovery of Patients Undergoing Gynecological Laparoscopic Surgery

Objective

To explore the effect of patient-controlled epidural analgesia (PCEA) based on enhanced recovery after surgery (ERAS) on the postoperative recovery of patients undergoing gynecological laparoscopic surgery.

Methods

Between January 2019 and December 2020, 90 patients scheduled for gynecological laparoscopic surgery and assessed for eligibility were recruited and randomly assigned at a ratio of 1 : 1 to receive either conventional analgesic management (regular group) or PCEA based on ERAS (ERAS group). Comparisons of postoperative rehabilitation indicators, visual analogue scale (VAS) score, self-care ability, complications, and nursing satisfaction were conducted between the two groups.

Results

The ERAS group had significantly shorter first exhaust time (FET), first defecation time (FDT), out-of-bed activity time (OAT), and length of stay (LOS) versus the regular group (P < 0.05). The VAS scores were significantly decreased after treatment, with lower results observed in the ERAS group (P < 0.05). The level of self-responsibility, self-concept, self-care skills, and health knowledge increased significantly in both groups after the intervention, and the ERAS group showed significantly higher results than the regular group (P < 0.05). The total incidence of complications in the ERAS group was significantly lower than that in the regular group (P < 0.05). Eligible patients given PCEA based on ERAS were associated with a higher nursing satisfaction (97.78%) versus conventional analgesic management (82.22%) (P < 0.05).

Conclusion

The application of ERAS for postoperative PCEA management in gynecological laparoscopy provides promising results by effectively enhancing the quality of surgery and promoting rapid postoperative recovery, with a good safety profile.

Application of the Concept of Enhanced Recovery after Surgery in Total Laparoscopic Radical Gastrectomy

To explore the clinical effects of total laparoscopic radical gastrectomy under the guidance of the concept of enhanced recovery after surgery (ERAS). Fifty-five patients were perioperatively treated under the concept of ERAS (ERAS group), while the remaining 55 patients were treated under the traditional perioperative concept (control group). The operation time, intraoperative blood loss, the time of first anal exhaust and first postoperative off-bed activity, postoperative length of stay, and incidence of postoperative complications were recorded in both groups. The pain of patients was assessed using VAS system. The nausea and vomiting and abdominal distension were assessed using the NVDS and abdominal distension score, respectively, within 24 h after operation. The patient's daily living ability was evaluated by the ADL scale at 3 d after the operation. The time of first anal exhaust, the time of first postoperative off-bed activity time, and the postoperative in-hospital time were all significantly shorter in the ERAS group than those in the control group (P < 0.001). The VAS score in the ERAS group was significantly lower than that in the control group at 12 h, 24 h, 48 h, and 72 h after operation (P < .001). The ERAS group had significantly lower NVDS score and abdominal distension score than the control group (P < 0.001). The postoperative ADL score in the ERAS group was significantly higher than that in the control group (P < 0.001). ERAS during the perioperative period of total laparoscopic radical gastrectomy can promote the postoperative rehabilitation of patients and alleviate postoperative pain and gastrointestinal reactions, which is safe and effective.

Feasibility of ERAS in Patients With Gastric Cancer Complicated by Diabetes Mellitus

Enhanced Recovery After Surgery (ERAS) is the integration of multiple perioperative evidence-based medical practices into a single pathway aimed at eliminating surgical liabilities and improving treatment accuracy to enhance patients' postoperative outcomes. The ERAS Society has been developing guidelines that are widely applicable in the surgical field. ERAS pathways in selective and noncomplicated cases are extensively practiced. However, the ERAS literature excludes patients with comorbidities, such as gastric cancer complicated with diabetes mellitus (DM). Current ERAS guidelines exclude patients with DM in enhanced recovery programs because of insufficient evidence-based medicine on the molecular physiology of the patients in response to surgical insult. Therefore, it is important to implement accelerated rehabilitation surgery for patients with gastric cancer and DM. This review discusses the feasibility and necessity of applying ERAS guidelines to patients with gastric cancer complicated by DM. In addition, we documented the need to lay a logical foundation for enhanced recovery after surgery in patients with gastric cancer complicated by DM.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery

OBJECTIVE

Data are sparse regarding the multidisciplinary perioperative enhanced recovery after surgery protocol (E-P) for thoracic esophageal cancer surgery that was newly used at another institution. Therefore, this study aimed to retrospectively evaluate the effectiveness and safety of the protocol.

METHODS

We enrolled 101 patients who underwent transthoracic esophagectomy for E-P at the Shizuoka Cancer Center Hospital (SCC). The outcomes obtained at the SCC were compared with the outcomes of 140 patients treated with E-P at the Saitama Medical University International Medical Center (SMU). At the SMU, we compared the results before and after the introduction of E-P.

RESULTS

The rates of morbidity, pulmonary complications, and postoperative pneumonia were 44%, 31%, and 6.9% at the SCC and 44%, 27%, and 6.5% at the SMU (P = 0.91, 0.55, and 0.88, respectively). The mean time to walk was 1.1 and 1.5 days at the SCC and SMU, respectively (P < 0.001). The median length of hospital stay was longer at the SMU than at the SCC (24.0 versus 20.8 days; P = 0.004). In the comparative study before and after the introduction of E-P, the rate of postoperative pneumonia was 16% in the conventional management group and 6.5% in the E-P group (P = 0.02).

CONCLUSION

Postoperative pneumonia was reduced before and after introduction of E-P. As similar short-term postoperative outcomes were promising (except for the time to walk and postoperative hospital stay), the same E-P that was safely performed at the SMU can be implemented as a standard practice.

Clinical efficacy of an enhanced recovery after surgery protocol in patients undergoing robotic-assisted laparoscopic prostatectomy

Objective

To evaluate the application of an enhanced recovery after surgery (ERAS) protocol in patients undergoing robot-assisted laparoscopic prostatectomy (RALP).

Methods

We conducted a retrospective cohort study of 136 patients who underwent RALP between August 2017 and June 2018 as the control group and a prospective analysis of 106 patients who underwent RALP between January 2019 and January 2020 as the ERAS group. ERAS focused on preoperative education, nutritional intervention, electrolyte solution intake, restrictive fluid infusion, body warming, no indwelling central venous catheter, use of nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and eating recovery.

Results

The times from RALP to the first intake of clear liquid; first ambulation; first defecation; first fluid, semi-liquid, and general diet; drain removal; and length of hospital stay (LOS) were significantly shorter, and operative time, fluid infusion within 24 hours, postoperative day (POD) 1 albumin, POD 1 hemoglobin, and POD 2 drainage were significantly higher in the ERAS group. Five patients (3.8%) in the ERAS group developed postoperative complications (urine leakage, n = 4; intestinal obstruction, n = 1), while 1 patient (0.7%) in the control group developed intestinal obstruction.

Conclusions

ERAS effectively accelerated patient rehabilitation and reduced the LOS for patients undergoing RALP.

Clinical benefits of a swallowing intervention for esophageal cancer patients after esophagectomy

Dysphagia after esophagectomy is the main cause of a prolonged postoperative stay. The present study investigated the effects of a swallowing intervention led by a speech-language-hearing therapist (SLHT) on postoperative dysphagia. We enrolled 276 consecutive esophageal cancer patients who underwent esophagectomy and cervical esophagogastric anastomosis between July 2015 and December 2018; 109 received standard care (control group) and 167 were treated by a swallowing intervention (intervention group). In the intervention group, swallowing function screening and rehabilitation based on each patient's dysfunction were led by SLHT. The start of oral intake, length of oral intake rehabilitation, and length of the postoperative stay were compared in the two groups. The patient's subgroups in the 276 patients were examined to clarify the more effectiveness of the intervention. The start of oral intake was significantly earlier in the intervention group (POD: 11 vs. 8 days; P = 0.009). In the subgroup analysis, the length of the postoperative stay was also significantly shortened by the swallowing intervention in patients without complications (POD: 18 vs. 14 days; P = 0.001) and with recurrent laryngeal nerve paralysis (RLNP) (POD: 30 vs. 21.5 days; P = 0.003). A multivariate regression analysis identified the swallowing intervention as a significant independent factor for the earlier start of oral intake and a shorter postoperative stay in patients without complications and with RLNP. Our proposed swallowing intervention is beneficial for the earlier start of oral intake and discharge after esophagectomy, particularly in patients without complications and with RLNP. This program may contribute to enhanced recovery after surgery.

Impact of Enhanced Recovery After Surgery on Long-Term Outcomes and Postoperative Recovery in Patients Undergoing Hepatectomy: A Retrospective Cohort Study

Background

The aim of this study was to evaluate the effects of implementation of the enhanced recovery after surgery (ERAS) program on postoperative recovery and the long-term prognosis in patients who underwent hepatectomy.

Methods

This retrospective study enrolled patients who underwent hepatectomy from January 2015 to December 2018 in Huadong Hospital Affiliated to Fudan University. Since June 2016, a 24-point ERAS protocol has been implemented for patients who underwent hepatic resection. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The secondary outcomes included length of stay (LOS), and incidence of postoperative complications.

Results

A total of 1143 patients were enrolled in this study. After propensity score matching (PSM), there was no significant difference in patients' demographic characteristics. The DFS at 1., 3 years in ERAS group was higher than in non-ERAS group (96.3% vs 88.9% for 1 year, P=0.012; 58.9% vs 46.7% for 3 years, P=0.007). The OS at 1, 3 years in ERAS group was higher than in non-ERAS group (93.1% vs 89.3% for 1 year, P=0.041; 68.7% vs 61.2% for 3 years, P=0.035). In addition, the patients in ERAS group had lower incidences of postoperative hemorrhage, bile leak, and postoperative deep vein thrombosis/pulmonary embolism (DVT/PE), decreased 30-day readmission rate and total readmission rate, and shorter LOS.

Conclusion

ERAS program could be safely applied to patients who underwent hepatectomy thereby improving their recovery and prolonging OS and DFS.

Total hip arthroplasty using hydroxyapatite-coated cementless cup for rapidly destructive coxarthrosis: Minimum 10-year follow-up

BACKGROUND

Performing total hip arthroplasty (THA) as early as possible is recommended for rapidly destructive coxarthrosis (RDC) as it causes pain that becomes progressively more severe. However, acetabular bone loss remains an issue in THA. Special devices, such as a Kerboull-type plate, may be used for acetabular bone defects, but the procedure is highly invasive and often the patients are elderly, further complicating matters. We retrospectively investigated the clinical and radiographic results of THA using conventional hydroxyapatite-coated cementless cup in RDC.

METHODS

A total of 32 patients (35 hips) with RDC were enrolled in the study with a minimum 10-year follow-up. All THAs were performed using conventional hydroxyapatite-coated cementless cup. All patients were evaluated clinically according to the Harris hip score (HHS). Acetabular bone deficiency was classified according to the American Academy of Orthopaedic Surgeons (AAOS) classification.

RESULTS

Eleven hips (31%) were AAOS type III, and none were type IV. Total HHS significantly improved from 36.5 to 79.4 (p < 0.01). Two cups exhibited loosening. The overall implant-associated survival rate after 10 years was 91.4%.

CONCLUSIONS

Clinical results of THA using conventional cementless implants for patients with RDC were acceptable. Thus, THA using conventional cementless implant is an effective and safe surgery for patients with RDC, minimizing surgical stress.

Effects of enteral nutrition support combined with enhanced recovery after surgery on the nutritional status, immune function, and prognosis of patients with esophageal cancer after Ivor-Lewis operation

Background

Esophageal cancer (EC) with a high incidence of malnutrition is a highly malignant digestive tract tumor. We investigated the effect of enteral nutrition (EN) support combined with enhanced recovery after surgery (ERAS) on the nutritional status, immune function, and prognosis of patients with EC after Ivor-Lewis operation.

Methods

One hundred patients were randomly divided into the observation group (n=42) and the control group (n=58). The patients in observation group were treated with EN combined with ERAS intervention after Ivor-Lewis operation, and the patients in control group were treated with conventional postoperative EN intervention. The situation of operation, nutritional status, immune function recovery and prognosis between the two groups were compared.

Results

There was no statistically significant difference in operation time or intraoperative blood loss between the two groups (P>0.05). The chest tube removal time and oral feeding time of the observation group after operation were shorter than those of the control group (P<0.05). After intervention, serum albumin (ALB), transferrin (TF), pre-albumin (PA) and hemoglobin (Hb) levels in both groups were significantly decreased. These indexes were significantly higher in the observation group than in the control group (P<0.05). There were no significant changes in the levels of immunoglobulin (Ig) A, IgG, and IgM, or the numbers of CD3⁺, CD4⁺ and CD4⁺/CD8⁺ T cells in the observation group before and after intervention (P>0.05); however those indexes were significantly decreased in the control group after the intervention (P<0.05). Interestingly, the levels of IgA, IgM, IgG, CD3⁺ T cells, CD4⁺ T cells and CD4⁺/CD8⁺ T cells in the observation group were significantly higher than those in the control group after intervention (P<0.05). The incidence of pulmonary infection in the observation group was significantly lower than that in the control group. The postoperative exhaust time, postoperative defecation time and postoperative hospital stay were shorter in the observation group than in the control group (P<0.05). There was no significant difference in hospitalization cost between the two groups (P>0.05).

Conclusions

EN combined with ERAS was more beneficial to the improvement of nutritional status and immune function recovery of patients with EC after Ivor-Lewis operation. It also shortened the length of hospital stay.

Does an enhanced recovery after surgery protocol affect perioperative surgical outcomes in stage III tubercular empyema? A comparative analysis of 243 patients

BACKGROUND

Enhanced recovery after surgery protocols in tuberculous empyema surgery have the potential for improved outcomes, but have not been studied widely. This study aimed to analyze the outcomes after implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tubercular empyema.

METHODS

A retrospective analysis of patients who underwent surgery for tuberculous empyema in a dedicated thoracic surgery center from March 2012 to March 2019 was performed. The control group included patients operated on between March 2012 and March 2016. The enhanced recovery after surgery protocol was strictly introduced into our practice from April 2016. The study group included patients operated on between April 2016 and March 2019. All perioperative outcomes were measured, documented, analyzed, and compared between the two groups. There were 166 patients in the control group and 77 in the study group.

RESULTS

Intraoperative blood loss (p = 0.0001), prolonged air leak (p = 0.04), chest tube duration (p = 0.005), and length of stay (p = 0.003) were significantly reduced in the study group. Overall rates of postoperative complications (p = 0.04) including wound infection (p = 0.01) were also significantly lower in the study group.

CONCLUSIONS

Implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tuberculous empyema is feasible and effective. Application of such a protocol leads to less intraoperative blood loss, shorter hospital stay and duration of chest drainage, and fewer complications. Application of enhanced recovery after surgery protocols are strongly recommended in tubercular empyema surgery.

Feeding jejunostomy in upper gastrointestinal resections: a UK-wide survey

INTRODUCTION

The usage of a feeding jejunostomy has been a well-established practice in maintaining nutrition in patients undergoing resections for upper gastrointestinal cancer. As surgical technique has evolved, together with the adoption of enhanced recovery after surgery pathways, the routine insertion of feeding jejunostomy tubes appears to be changing.

MATERIALS AND METHODS

A survey was constructed using Google Forms. The link was distributed to consultant upper gastrointestinal surgeons via the Association of Upper Gastrointestinal Surgeons' membership database. Results were collated and analysed using Microsoft Excel.

RESULTS

A total of 55 responses were received from 28 units across the UK; 27 respondents (49.1%) no longer routinely use feeding jejunostomy in upper gastrointestinal resections, oesophagectomy or gastrectomy. The most common primary feeding modality used by these respondents was oral diet 17 (65.4%), with total parenteral nutrition (19.2%) and nasojejunal (11.5%) routes also being used. Respondents who used feeding jejunostomies inserted them primarily for oesophagectomy (n = 27; 96.4%), with fewer surgeons using them in extended total gastrectomy (n = 12; 42.9%) and total gastrectomy (n = 11; 39.3%). Of the total, 20 surgeons (71.4%) would insert the jejunostomy using an open approach, with 19 (67.9%) employing a Witzel tunnel. Eleven respondents (39.3%) would continue feeding via the jejunostomy after discharge. Some 24 responders thought that feeding jejunostomies did not facilitate the enhanced recovery after surgery pathway (strongly and slightly disagree), whereas 17 considered that they did (strongly and slightly agree); 13 responders did not have strong views either way.

CONCLUSIONS

There is a split in current practice regarding the usage of feeding jejunostomies. There is also a division of opinion on the role of feeding jejunostomy in enhanced recovery after surgery.

Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach

Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO₂/FiO₂ ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman's rank correlation coefficient (r_sp) = -0.267, p = 0.006), especially of laparotomy (r_sp = -0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1-25) and 8.5 (3-14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.

Unmet supportive care needs and associated factors among Chinese discharged patients with esophageal cancer after esophagectomy: A cross-sectional study

PURPOSE

After esophagectomy, patients experience a series of problems that severely affect their quality of life. Understanding their unmet needs could help medical staff provide better supportive care. The aim of this study was to investigate the supportive care needs of discharged patients with esophageal cancer after esophagectomy and explore the factors associated with these needs.

METHOD

A total of 167 discharged patients with esophageal cancer after esophagectomy were recruited from a University Cancer Center in China and investigated using a self-designed demographic and clinical characteristics questionnaire, the 34-item Supportive Care Needs Survey, and the M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module.

RESULTS

Approximately 95.2% of the patients had ≥1 unmet need(s). The overall level of supportive care needs of patients after esophagectomy was mild to medium. Most of the top 10 moderate-to-severe unmet needs were identified in the health and information domains. Age (β = -0.157, p = 0.011), dysphagia (β = -0.178, p = 0.005), recurrence (β = 0.175, p = 0.005), time since diagnosis (β = -0.150, p = 0.018), and symptom interference (β = 0.488, p < 0.001) were significantly associated with supportive care needs.

CONCLUSIONS

Discharged patients with esophageal cancer after esophagectomy had a wide range of unmet supportive care needs. It is essential to combine the associated factors to accurately evaluate patient needs. We should pay more attention to propose comprehensive measures for these patients and provide more individualized supportive care during the lengthy recovery period.

High compliance to ERAS protocol does not improve overall survival in patients treated for resectable advanced gastric cancer

Introduction

The ERAS (Enhanced Recovery after Surgery) protocol revolutionized perioperative care for gastrointestinal surgical procedures. However, little is known about the association between adherence to the ERAS protocol in gastric cancer surgery and the oncological outcome.

Aim

To explore the relation between adherence to the ERAS protocol and the oncological outcome in gastric cancer patients.

Material and methods

We performed a retrospective analysis of a prospectively collected database of patients treated for gastric cancer between 2013 and 2016. All patients were treated perioperatively with a 14-item ERAS protocol. Every patient underwent regular follow-up every 3 months for 3 years after surgery. 80% compliance to the ERAS protocol was the goal during perioperative care. Based on the level of compliance, patients were divided into group 1 and group 2 (compliance of ≥ 80% and < 80%, respectively).

Results

Compliance to the ERAS protocol was not a risk factor for diminished overall survival – probability of 3-year survival was 63% in group 1 and 56% in group 2 (p = 0.75). The proportional Cox model revealed that only stage III gastric cancer was a risk factor of poor prognosis in patients operated on for gastric cancer (HR = 7.89, 95% CI: 2.96–20.89; p = 0.0001).

Conclusions

High adherence to the ERAS protocol did not improve overall survival in our 3-year observation. Only the stage of the disease, according to the AJCC classification, was identified as a risk factor for poor prognosis.