Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients

Promoting application of enhanced recovery after surgery protocols during perioperative localized abdominal and thoracic neuroblastomas

AIM

To investigate the safety and efficacy of the application of enhanced recovery after surgery (ERAS) protocols in the perioperative period of abdominal and thoracic localized neuroblastomas (NBs).

METHODS

In this retrospective study, 68 children with NBs who underwent surgical resection of the tumor were enrolled. The ERAS protocols for NB excision were implemented in the ERAS group (n = 39) and the consequences were compared with children treated with traditional care (n = 29, TRAD group). The main outcomes of our interest included the incidence of surgery-related complications, the postoperative length of stay (LOS), and the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table from postoperative days (POD) 1-5. We also evaluated the median intraoperative fluid volume and anesthesia recovery time; blood glucose levels at the beginning of anesthesia, POD1, and 3; WBC counts, CRP values, and the concentration of plasma nutritional indicators on POD1 and 3; time of early ambulation, first anal exhaust, total enteral nutrition (TEN), and discontinue intravenous infusion postoperatively; usage proportion and duration of abdominal and thoracic drainages, nasogastric decompression tubes and urinary catheters; cost of hospitalization, parental satisfaction rate, and readmission rate of surgery ward within 30 days.

RESULTS

Compared to the TRAD group, the ERAS group had lower surgery-related complications, albeit not significantly (P > 0.05); the median postoperative LOS decreased from 11.0 to 8.0 days (P < 0.001), the LOS of abdominal NB was significantly shortened (P < 0.001) compared to thoracic NB (P = 0.07) between the two groups; the FLACC scores decreased significantly from POD1-5 (all P < 0.01). The ERAS group had an improved median intraoperative infusion speed (5.0 mL/kg/h vs 8.0 mL/kg/h), time of early ambulation (1.0 days vs 3.0 days), first anal exhaust (2.0 days vs 2.0 days), TEN (5.0 vs 7.0 days), discontinuation of intravenous infusion (5.0 days vs 8.0 days), and total cost of hospitalization (33,897.2 Yuan vs 38,876.3 Yuan); (all P < 0.01). The usage proportion and duration of surgical drainages and tubes were apparently reduced. The mean blood glucose level was higher at the beginning of anesthesia but lower on POD1 and 3 in the ERAS group (P < 0.01). No statistically significant difference was detected in WBC counts and concentrations of hemoglobin and albumin between the two groups of patients (P > 0.05), while the concentrations of prealbumin on POD3 were higher and the CRP level on POD1 was lower in the ERAS group than the TRAD group (P < 0.01). The satisfaction rate of parents was only slightly higher, but the difference was not statistically significant (P = 0.730). No obvious differences were observed in the aspects of NB resection (P = 0.462) and 30-day readmissions of surgery ward (P = 1.000).

CONCLUSION

The application of ERAS protocols has a significant potential to accelerate perioperative rehabilitation in children undergoing abdominal and thoracic NBs' surgical resection.

An Enhanced Recovery Program for Pediatric, Adolescent, and Young Adult Surgical Oncology Patients Improves Outcomes After Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS®) is a standardized perioperative approach that utilizes a multidisciplinary team to reduce physiologic stress and improve postoperative recovery. The purpose of our study is to evaluate outcomes in pediatric, adolescent, and young adult (AYA) patients undergoing major oncologic operations before and after the implementation of an enhanced recovery program (ERP).

METHODS

All patients ≤23 years old who underwent major oncologic surgery between 1/2017-2/2022 were identified. ERP was implemented on 6/7/2021, with all patients enrolling on ERP after that date. Pre-ERP patients were selected based on similar age, diagnosis, and operations. The Mann-Whitney U-test was used to compare continuous variables, and the chi-squared test or Fisher exact test as appropriate to compare categorical variables between Pre-ERP and ERP patients.

RESULTS

A total of 47 patients were included (28 Pre-ERP, 19 ERP). The median age was 14 years (range, 1-23). 18 underwent thoracotomy, 26 laparotomy, and 3 chest wall resections. Results suggest that ERP patients had significantly shorter time to ambulation (25 h; p = 0.004) and postoperative length of stay (LOS; 3 days; p < 0.001). Two patients in the ERP group required zero narcotics after operation.

CONCLUSION

We found initial evidence that the implementation of an ERP for pediatric, AYA patients resulted in positive postoperative outcomes - a decrease in postoperative LOS and promoted early mobility without an increase in readmission rates. Enhanced recovery programs should be incorporated into the care of pediatric, AYA oncology patients undergoing oncologic surgery.

LEVEL OF EVIDENCE

Retrospective Comparative Study - Level III.

Development of an enhanced recovery after surgery program for pediatric solid tumors

Introduction

Enhanced recovery after surgery (ERAS) is an evidence-based, multi-modal approach to decrease surgical stress, expedite recovery, and improve postoperative outcomes. ERAS is increasingly being utilized in pediatric surgery. Its applicability to pediatric patients undergoing abdominal tumor resections remains unknown.

Methods and Analysis

A group of key stakeholders adopted ERAS principles and developed a protocol suitable for the variable complexity of pediatric abdominal solid tumor resections. A multi-center, prospective, propensity-matched case control study was then developed to evaluate the feasibility of the protocol. A pilot-phase was utilized prior to enrollment of all patients older than one month of age undergoing any abdominal, retroperitoneal, or pelvic tumor resections. The primary outcome was 90-day complications per patient. Additional secondary outcomes included: ERAS protocol adherence, length of stay, time to administration of adjuvant chemotherapy, readmissions, reoperations, emergency room visits, pain scores, opioid usage, and differences in Quality of Recovery 9 scores.

Ethics and Dissemination

Institutional review board approval was obtained at all participating centers. Informed consent was obtained from each participating patient. The results of this study will be presented at pertinent society meetings and published in peer-reviewed journals. We expect the results will inform peri-operative care for pediatric surgical oncology patients and provide guidance on initiation of ERAS programs. We anticipate this study will take four years to meet accrual targets and complete follow-up.

Trial Registration Number

NCT04344899.

Retroperitoneoscopic or Transperitoneal Approach for Neurogenic and Adrenal Tumors in Children? A Comparison on the Way to Enhanced Recovery in Pediatric Surgical Oncology

BACKGROUND

Minimally invasive surgery is increasingly utilized for resection of neurogenic tumors in children. The minimally invasive retroperitoneoscopic approach was recently reported in children, but transperitoneal laparoscopy still remains the most common technique. The aim of this study is to compare a novel single-port retroperitoneoscopy (SPR) approach for pediatric neurogenic tumor resection with transperitoneal laparoscopic (TPL).

METHODS

Patients undergoing minimally invasive resection of abdominal neurogenic tumors over 5 years at a single institution (from 2018 to 2022) were retrospectively reviewed. Tumor volume, stage, presence of image-defined risk factors (IDRFs), neoadjuvant chemotherapy, operative time, estimated blood loss (EBL), length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), and time to chemotherapy were assessed and compared with SPR and TPL approaches.

RESULTS

Eighteen and fifteen patients underwent TPL and SPR, respectively. No significant differences were found between the TPL and SPR approaches in terms of tumor characteristics and IDRFs. Patients who underwent SPR had a significantly faster recovery (p = 0.008) and less postoperative opioid use compared to those in TPL (p = 0.02), thus allowing an enhanced recovery after surgery (ERAS) protocol application. TPL and SPR approaches were performed in presence of IDRFs, respectively in 2 (11%) and 4 patients (27%), with a IDRFs-related conversion in one TPL procedure. Both approaches had one < Grade 3 Clavien Dindo complication, but not requiring further surgery.

DISCUSSION

SPR approach can be considered as a safe and feasible minimally invasive approach for the resection of pediatric primary adrenal and neurogenic tumors. The retroperitoneoscopic approach performed using a single port technique represents a promising new frontier of ERAS application in pediatric surgical oncology.

CONCLUSION

SPR is a viable surgical alternative in selected neurogenic abdominal tumors with limited IDRFs, thus allowing for the application of ERAS protocols in these patients.

LEVEL OF EVIDENCE

Level III.

Epidural Analgesia Is Associated With Reduced Inpatient Opioid Consumption and Length of Stay After Wilms Tumor Resection

INTRODUCTION

Wilms' tumor (WT) is the most common renal malignancy in children and requires an extensive laparotomy for resection. Epidural analgesia (EA) is commonly used in postoperative pain management, but previous literature suggests it may prolong length of stay (LOS). We hypothesized that EA is associated with prolonged LOS but decreased postoperative opioid use in children undergoing WT resection.

MATERIALS AND METHODS

A retrospective chart review was performed for all WT patients who underwent nephrectomy between January 1, 1998, and December 31, 2018, at a tertiary children's hospital. Patients with incomplete records, bilateral WT, caval or cardiac tumor extension, or intubation postoperatively were excluded. Outcomes included postoperative opioid consumption measured in oral morphine equivalents per kilogram, receipt of opioid prescription at discharge, and postoperative LOS. Mann-Whitney and multivariable regression analyses were performed.

RESULTS

Overall, 46/77 children undergoing WT resection received EA. Children with EA used significantly less inpatient opioids than children without EA (median 1.0 vs. 3.3 oral morphine equivalents per kilogram; P < 0.001). Comparing patients with EA to patients without, there was no significant difference in opioid discharge prescriptions (57% vs. 39%; P = 0.13) or postoperative LOS (median 5 d vs. 6 d; P = 0.10). Controlling for age and disease stage, EA was associated with shorter LOS by multivariable regression (coefficient -0.73, 95% confidence interval: -1.4, -0.05; P = 0.04).

CONCLUSIONS

EA is associated with decreased opioid use in children without an associated increase in postoperative LOS following WT resection. EA should be considered as part of multimodal pain management for children undergoing WT resection.

Retroperitoneal localized neuroblastoma in children: a comparison of enhanced recovery after surgery versus traditional care

PURPOSE

To investigate the clinical value of enhanced recovery after surgery (ERAS) protocols for children with neuroblastoma (NB).

METHODS

This retrospective review was conducted by using the electronic medical records of 48 children with retroperitoneal localized NB who underwent tumor resection (surgery for treatment, not diagnosis) between October 2016 and September 2021. The ERAS protocols for NB excision were implemented in 28 children (ERAS group), while 20 children received traditional care (TRAD group). The same group of pediatric surgeons performed all the tumor resections. Intraoperative fluid infusion, the extent of NB resection, time of early ambulation and time of first flatus, time to total enteral nutrition (TEN) after surgery, abdominal drainages, nasogastric tubes and urinary catheters used and duration, the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table on a postoperative day 1 (POD1), 3, 5, length of stay after surgery (LOS), hospitalization expense, postoperative complications, parental satisfaction rate and readmission rate of surgical wards within 30 days after operation were analyzed.

RESULTS

The median postoperative period of early mobilization, first flatus, TEN, LOS and total cost during hospitalization were 1.0 days, 2.0 days, 5.5 days, 9.0 days and 33,397.3 yuan in the ERAS group and 3.0 days, 3.0 days, 7.0 days, 11.0 days and 38,120.3 Yuan in the TRAD group, respectively (all p < 0.05). Median intraoperative fluid volume was 5.0 mL/kg/h compared to 8.0 mL/kg/h and the magnitude of decrease in FLACC scores from POD1 to POD5 was greater in the ERAS group (all p < 0.05). Abdominal drainages, urinary catheters and nasogastric tubes were removed earlier in the ERAS group (p < 0.05). The satisfaction of parents in the ERAS group was slightly higher, but the difference was not statistically significant (P = 0.762). There were no marked differences between the two groups in aspects of the extent of NB resection, operation-related complications and 30-day readmissions (all P = 1.000).

CONCLUSIONS

Application of ERAS protocols in localized retroperitoneal NBs resection in children is feasible and safe. However, applying ERAS protocols in the surgical resection of solid tumors in children still requires much more research, especially randomized prospective research.

Implementing Rounding Checklists in a Pediatric Oncologic Intensive Care Unit

Standardized rounding checklists during multidisciplinary rounds (MDR) can reduce medical errors and decrease length of pediatric intensive care unit (PICU) and hospital stay. We added a standardized process for MDR in our oncologic PICU. Our study was a quality improvement initiative, utilizing a four-stage Plan–Do–Study–Act (PDSA) model to standardize MDR in our PICU over 3 months, from January 2020 to March 2020. We distributed surveys to PICU RNs to assess their understanding regarding communication during MDR. We created a standardized rounding checklist that addressed key elements during MDR. Safety event reports before and after implementation of our initiative were retrospectively reviewed to assess our initiative’s impact on safety events. Our intervention increased standardization of PICU MDR from 0% to 70% over three months, from January 2020 to March 2020. We sustained a rate of zero for CLABSI, CAUTI, and VAP during the 12-month period prior to, during, and post-intervention. Implementation of a standardized rounding checklist may improve closed-loop communication amongst the healthcare team, facilitate dialogue between patients’ families and the healthcare team, and reduce safety events. Additional staffing for resource RNs, who assist with high acuity patients, has also facilitated bedside RN participation in MDR, without interruptions in clinical care.

Pain and Analgesia in Children with Cancer after Hemipelvectomy: A Retrospective Analysis

A paucity of data exists centering on the pain experience of children following hemipelvectomy performed for primary bone and soft tissue sarcomas. In this study, we aimed to describe the incidence, severity, and evolution of perioperative pain and function in pediatric oncology patients undergoing hemipelvectomy, and, additionally, we sought to detail the analgesic regimens used for these patients perioperatively. A retrospective chart review was conducted, studying cancer patients, aged 21 years and under, who underwent hemipelvectomy at MD Anderson Cancer Center (MDACC) from 2018 to 2021. Primary outcomes included the evolution of pain throughout the perioperative course, as well as the route, type, dose, and duration of analgesic regimens. Eight patients were included in the analysis. The mean age at operation was 13 ± 2.93 years. All patients received opioids and acetaminophen. The mean pain scores were highest on post-operative day (POD)0, POD5, and POD 30. The mean opioid use was highest on POD5. A total of 75% of patients were noted to be ambulating after hemipelvectomy. The mean time to ambulation was 5.33 ± 2.94 days. The combination of acetaminophen with opioids, as well as adjunctive regional analgesia, non-steroidal anti-inflammatory drugs, gabapentin, and/or ketamine in select patients, appeared to be an effective analgesic regimen, and functional outcomes were excellent in 75% of patients.