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Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open 2024; 7:e2417310. [PMID: 38888922 PMCID: PMC11195621 DOI: 10.1001/jamanetworkopen.2024.17310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/20/2024] Open
Abstract
Importance A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. Objective To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. Data Sources MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Study Selection Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data Extraction and Synthesis Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. Main Outcome and Measures The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Results Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. Conclusions and Relevance In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.
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Affiliation(s)
- Khara M. Sauro
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology and Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christine Smith
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seremi Ibadin
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abigail Thomas
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Linda Bakunda
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bishnu Bajgain
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven P. Bisch
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Pandrangi VC, Araujo A, Buncke M, Olson B, Jorizzo M, Said-Al-Naief N, Sanusi O, Ciporen J, Shindo M, Schindler J, Colaianni CA, Clayburgh D, Andersen P, Flint P, Wax MK, Geltzeiler M, Li RJ. Patterns of virtual reality and Fitbit wearable activity device use after skull base surgery. Int Forum Allergy Rhinol 2024. [PMID: 38739098 DOI: 10.1002/alr.23364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/24/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
KEY POINTS Virtual reality (VR) and Fitbit devices are well tolerated by patients after skull base surgery. Postoperative recovery protocols may benefit from incorporation of these devices. However, challenges including patient compliance may impact optimal device utilization.
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Affiliation(s)
- Vivek C Pandrangi
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ana Araujo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Michelle Buncke
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Brennan Olson
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Jorizzo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Olabisi Sanusi
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeremy Ciporen
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Maisie Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Joshua Schindler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - C Alessandra Colaianni
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Clayburgh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paul Flint
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ryan J Li
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Ashfaq A, Bokhari SFH, Rehman A, Baluch AB, Mohamed Abdul Raheem AB, Almomani MM, Al-Shaikhly FF, I Kh Almadhoun MK, Kamran M, Shehzad A. Navigating the Surgical Landscape: A Comprehensive Analysis of Endoscopic vs. Microscopic Transsphenoidal Pituitary Surgery Outcomes. Cureus 2024; 16:e53633. [PMID: 38449928 PMCID: PMC10915695 DOI: 10.7759/cureus.53633] [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: 01/29/2024] [Indexed: 03/08/2024] Open
Abstract
Pituitary surgery, a critical intervention for various pituitary disorders, has sparked ongoing debates regarding the preference between endoscopic and microscopic transsphenoidal approaches. This systematic review delves into the outcomes associated with these techniques, taking into account the recent advancements in neurosurgery. The minimally invasive nature of endoscopy, providing improved visualization and reduced morbidity, stands in contrast to the well-established track record of the conventional microscopic method. Examining outcomes for disorders such as Cushing's disease and acromegaly, the review synthesizes evidence from Denmark, Bulgaria, and China. Noteworthy advantages of endoscopy encompass higher resection rates, shorter surgery durations, and fewer complications, endorsing its effectiveness in pituitary surgery. While emphasizing the necessity for prospective trials, the review concludes that endoscopic approaches consistently showcase favorable outcomes, influencing the ongoing discourse on the optimal surgical strategies for pituitary disorders.
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Affiliation(s)
- Abdullah Ashfaq
- Surgery, Gujranwala Medical College Teaching Hospital, Gujranwala, PAK
| | | | | | - Amna B Baluch
- Internal Medicine, Universidad Autónoma de Guadalajara, Guadalajara, MEX
| | | | | | | | | | | | - Ahsan Shehzad
- Surgery, King Edward Medical University, Lahore, PAK
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Pelargos PE, Hasanjee A, Lee B, Grossen A, Prather KY, Zhao X, Ohene-Nyako P, Baier MP, McDaniel AK, McKinney KA, Graffeo CS, Rassi EE, Dunn IF. An institutional experience in applying quality improvement measures to pituitary surgery: clinical and resource implications. Neurosurg Focus 2023; 55:E10. [PMID: 38039538 PMCID: PMC10798057 DOI: 10.3171/2023.9.focus23545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/28/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations. METHODS Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022). RESULTS Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498. CONCLUSIONS CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.
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Affiliation(s)
- Panayiotis E. Pelargos
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Aamr Hasanjee
- Department of Otolaryngology–Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Benjamin Lee
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Audrey Grossen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kiana Y. Prather
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Xiaochun Zhao
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Prince Ohene-Nyako
- Department of Otolaryngology–Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Matthew P. Baier
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amanda Kate McDaniel
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kibwei A. McKinney
- Department of Otolaryngology–Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Christopher S. Graffeo
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Edward El Rassi
- Department of Otolaryngology–Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ian F. Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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Flukes S, Laufer I, Cracchiolo J, Geer E, Lin AL, Brallier J, Tsui V, Afonso A, Tabar V, Cohen MA. Integration of an enhanced recovery after surgery program for patients undergoing pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2022; 8:330-338. [PMID: 36474665 PMCID: PMC9714042 DOI: 10.1016/j.wjorl.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/01/2021] [Indexed: 02/09/2023] Open
Abstract
Evidence-based enhanced recovery after surgery (ERAS) programs aim to improve patient outcomes and shorten hospital stays. The objective of this study is to describe the development, implementation, and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors. A systematic review of the literature was performed, best practices were discussed with stakeholders, and institutional guidelines were established and implemented. Key performance indicators (KPI) were measured and patient-reported outcome surveys were collected. The ERAS protocol was introduced successfully at our institution. We describe the process of initiation of the program and the perioperative management of our patients. We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement, with a particular emphasis on the use of data informatics and metrics to monitor outcomes. We expect that this approach will translate to improved quality of care for these often-complex patients.
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Affiliation(s)
- Stephanie Flukes
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Ilya Laufer
- Department of NeurosurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jennifer Cracchiolo
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Andrew L. Lin
- Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jess Brallier
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Van Tsui
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Anoushka Afonso
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Viviane Tabar
- Department of NeurosurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Marc A. Cohen
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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