Evidence or eminence in abdominal surgery: Recent improvements in perioperative care

Evaluation of the Effect of the Pre-Operative Exercise Training on Weight Loss, Quality of Life, and Cardiopulmonary Parameter in Bariatric Metabolic Surgery: A Systematic Review and Meta-Analysis

The purpose of this study is to assess the impact of pre-surgery exercise training on cardiopulmonary fitness. Ten articles (six RCTs and four non-RCTs) involving 281 individuals were finally included in the synthesis. Regarding the effect on VO2 peak, overall standardized mean differences were 0.71 (95% CI, 0.31 to 1.11, n = 103) with heterogeneity (I2 = 0%, P = 0.49). For 6MWT, overall weighted mean differences (distance in meters) were 31.87 (95% CI, 27.84 to 35.89, n = 100) with heterogeneity (I2 = 0%, P = 0.96). Engaging in pre-bariatric metabolic surgery exercise training might improve anthropometric parameters and cardiopulmonary fitness with no significant changes in components of quality of life. However, considering high levels of heterogeneity, the results should be generalized cautiously.

Effects of Supervised Physical Exercise as Prehabilitation on Body Composition, Functional Capacity and Quality of Life in Bariatric Surgery Candidates: A Systematic Review and Meta-Analysis

Background: Prehabilitation is a strategy used aiming to reduce the risk factors and complications of surgery procedures, but there is no consensus on the effectiveness of supervised physical exercise and its optimal prescription during this phase. Objectives: To determine the effects of exercise prehabilitation on body composition, functional capacity and quality of life in candidates for bariatric surgery. Search methods: A search was conducted in PubMed, Web of Science, SciELO, Scopus, MEDLINE and CINAHL. Selection criteria: Only randomized clinical trials that examined the effectiveness of supervised physical exercise were included. The main outcomes were body composition, functional capacity, quality of life and surgical outcomes. Data collection and analysis: Two researchers independently selected the literature, extracted the data and evaluated the risk of bias. A third researcher was consulted when a consensus was not reached. The risk of bias was assessed by the tool recommended by the Cochrane Collaboration, the quality of the evidence by GRADE, and to analyze the effects of prehabilitation on the primary objectives, RevMan software, version 5.3 was used. Main results: The search resulted in 4550 articles, of which 22 met the eligibility criteria, leaving 5 articles selected for this review. One article was assessed as a high bias risk and four as an uncertain risk, which included 139 candidates for bariatric surgery. Most of the studies evaluated the body composition, functional capacity and quality of life; none reported surgical outcomes. Conclusions: Supervised physical exercise has positive effects on the body composition, functional capacity and quality of life; there was no evidence for surgical outcomes, which opens up a field of study for future research of this population.

Knowledge of enhanced recovery after surgery and influencing factors among abdominal surgical nurses: a multi-center cross-sectional study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are well established. Evidence describing nurses' knowledge of ERAS is limited.

AIM

To assess surgical nurses' knowledge of ERAS and identify factors that correlate with knowledge level.

DESIGN

An anonymous cross-sectional survey via an online social platform was conducted in the abdominal surgical specialty of 40 hospitals in ten cities in China.

METHODS

Nurses of abdominal surgery in hospitals were enrolled in this study. A self-administered questionnaire that was reviewed by an expert panel was used to assess the knowledge of ERAS in nurses. A generalised linear regression analysis was used to assess factors associated with nurses' knowledge regarding ERAS.

RESULTS

Overall survey participation was 91.8% (2230/2430). The mean score of ERAS-related knowledge among abdominal surgical nurses was 12.10 (SD = 3.79). ERAS knowledge differed according to gender, age, education level, professional title, years of working, specialised working years, ERAS training experience, surgical department, and type of hospital (p < 0.05).

CONCLUSIONS

Chinese nurses employed in abdominal surgical services need to improve the knowledge about ERAS protocols. Standardised training is recommended to improve nurses' ERAS-related knowledge, which can help nurses improve the quality of perioperative care and promote the recovery of patients.

Statin Therapy Is Associated With Decreased 90-Day Postoperative Mortality After Colon Cancer Surgery

BACKGROUND

There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery.

OBJECTIVE

This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery.

DESIGN

This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register.

SETTINGS

Patient inclusion was achieved through a nationwide register.

PATIENTS

All adult patients undergoing elective surgery for colon cancer between January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin-positive cohort.

MAIN OUTCOME MEASURES

The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality.

RESULTS

A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and being less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, due to multiorgan failure, or resulting from a cardiovascular and respiratory origin.

LIMITATIONS

The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded.

CONCLUSIONS

Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study; however, further research is needed to ascertain whether this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738.

LA TERAPIA CON ESTATINAS SE ASOCIA CON UNA DISMINUCIN DE LA MORTALIDAD POSOPERATORIA A LOS DAS DESPUS DE LA CIRUGA DE CNCER DE COLON

ANTECEDENTES:Ha habido informes contradictorios con respecto al efecto protector de la terapia con estatinas después de la cirugía de cáncer de colon.OBJETIVO:Este estudio tuvo como objetivo evaluar la asociación entre la terapia con estatinas y la mortalidad postoperatoria después de la cirugía electiva por cáncer de colon.DISEÑO:Este estudio de cohorte poblacional es un análisis retrospectivo de datos recopilados prospectivamente del Registro Sueco de Cáncer Colorrectal.AJUSTES:La inclusión de pacientes se logró mediante la inclusión a través de un registro a nivel nacional.PACIENTES:Se incluyeron en el estudio todos los pacientes adultos sometidos a cirugía electiva por cáncer de colon en el período de enero de 2007 y septiembre de 2016. Los pacientes que habían recibido y recogido una receta de estatinas antes y después de la operación fueron asignados a la cohorte positiva de estatinas.PRINCIPALES MEDIDAS DE DESENLACES:Los desenlaces primarios y secundarios de interés fueron la mortalidad por cualquier causa a los 90 días y la mortalidad por causas específicas a los 90 días.RESULTADOS:Un total de 22.337 pacientes se sometieron a cirugía electiva por cáncer de colon durante el período de estudio, de los cuales 6.494 (29%) se clasificaron como usuarios de estatinas. Los usuarios de estatinas mostraron un beneficio significativo en la supervivencia a pesar de ser mayores, de tener una mayor carga de comorbilidad y de estar menos acondicionado para la cirugía. El análisis multivariado ilustró reducciones significativas en el riesgo de incidencia de mortalidad por cualquier causa a 90 días (índice de tasa de incidencia = 0,12, p < 0,001), así como muertes específicas ena 90 días debidas a sepsis, falla multiorgánica o dea enfermedades de origen cardiovascular y respiratorio.LIMITACIONES:Las limitaciones de este estudio incluyen su diseño observacional retrospectivo, que restringe la capacidad de realizar un seguimiento estandarizado de la terapia con estatinas. No se puede excluir confusión a partir de otras variables no controladas.CONCLUSIONES:Los usuarios de estatinas tuvieron un beneficio posoperatorio significativo con respecto a la mortalidad a corto plazo después de cirugía electiva por cáncer de colon en el estudio actual, sin embargo, se necesita más investigación para confirmar si eexiste una relación es causal. Consulte Video Resumen en http://links.lww.com/DCR/B738.

The impact of enhanced recovery pathways on cost of care and perioperative outcomes in patients undergoing gastroesophageal and hepatopancreatobiliary surgery

INTRODUCTION

Enhanced recovery after surgery protocols have been increasingly adopted to standardize patient care and decrease overall costs. This study evaluated the impact of a prospectively implemented enhanced recovery after surgery protocol for patients undergoing surgery for gastroesophageal and hepatopancreatobiliary disease at an academic institution.

METHODS

Patients undergoing either hepatopancreatobiliary or gastroesophageal procedures between January 2013 and May 2017 were classified according to whether or not they were placed on an enhanced recovery after surgery protocol. Groups were compared along demographic, perioperative, outcomes, and financial variables.

RESULTS

Of a total of 377 patients, 149 were placed on an enhanced recovery after surgery protocol. There was a significant association between enhanced recovery after surgery protocol use and increased perioperative antibiotic use (98.0% enhanced recovery after surgery vs. 87.3% non-enhanced recovery after surgery, P < .001), decreased intraoperative crystalloid use (1,155 ± 705 mL enhanced recovery after surgery vs. 1,576 ± 826 non-enhanced recovery after surgery, P < .001), decreased requirement for intensive care unit stay (20.1% enhanced recovery after surgery vs. 36.4% non-enhanced recovery after surgery, P < .001), and decreased total hospital costs ($10,688.38 ± 10,518.22 vs. $15,439.22 ± 14,201.24, P < .001). On multivariable analysis, enhanced recovery after surgery protocol use was independently associated with decreased rate of intensive care unit admission (odds ratio 0.39, 95% confidence interval 0.23-0.66, P < .001).

CONCLUSION

Enhanced recovery after surgery pathways can be safely implemented in patients undergoing hepatopancreatobiliary and gastroesophageal procedures and can help standardize perioperative practices, decrease requirement for intensive care unit admission, and decrease total hospital costs.

Best practice in major elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS)

Within traditional clinical care, the postoperative recovery after pelvic/rectal surgery has been slow with high morbidity and long hospital stay. The enhanced recovery after surgery program is a multimodal approach to perioperative care designed to accelerate recovery and safely reduce hospital stay. This review will briefly summarize optimal perioperative care, before, during and after surgery in this group of patients and issues related to implementation and audit.

Systematic review and meta-analysis of frailty as a predictor of morbidity and mortality after major abdominal surgery

Background

Frailty is associated with poor prognosis, but the multitude of definitions and scales of assessment makes the impact on outcomes difficult to assess. The aim of this study was to quantify the effect of frailty on postoperative morbidity and mortality, and long‐term mortality after major abdominal surgery, and to evaluate the performance of different frailty metrics.

Methods

An extended literature search was performed to retrieve all original articles investigating whether frailty could affect outcomes after elective major abdominal surgery in adult populations. All possible definitions of frailty were considered. A random‐effects meta‐analysis was carried out for all outcomes of interest. For postoperative morbidity and mortality, overall effect sizes were estimated as odds ratios (OR), whereas the hazard ratio (HR) was calculated for long‐term mortality. The potential effect of the number of domains of the frailty indices was explored through meta‐regression at moderator analysis.

Results

A total of 35 studies with 1 153 684 patients were analysed. Frailty was associated with a significantly increased risk of postoperative major morbidity (OR 2·56, 95 per cent c.i. 2·08 to 3·16), short‐term mortality (OR 5·77, 4·41 to 7·55) and long‐term mortality (HR 2·71, 1·63 to 4·49). All domains were significantly associated with the occurrence of postoperative major morbidity, with ORs ranging from 1·09 (1·00 to 1·18) for co‐morbidity to 2·52 (1·32 to 4·80) for sarcopenia. No moderator effect was observed according to the number of frailty components.

Conclusion

Regardless of the definition and combination of domains, frailty was significantly associated with an increased risk of postoperative morbidity and mortality after major abdominal surgery.

Minimally Invasive Distal Pancreatectomy: Review of the English Literature

BACKGROUND

Recently, the superiority of the minimally invasive approach, which results in a better cosmetic result, faster recovery, and shorter length of hospital stay, is a technique that has been progressively recognized as it has developed. And the minimally invasive approach has been applied to distal pancreatectomy (DP), which is a standard method for the treatment of benign, borderline, and part of malignant lesions of the pancreatic body and tail. This article aims to analyze the types, postoperative recovery, and outcomes of laparoscopic distal pancreatectomy (LDP).

MATERIALS AND METHODS

A systematic search of the scientific literature was performed using PubMed, EMBASE, online journals, and the Internet for all publications on LDP. Articles were selected if the abstract contained patients who underwent LDP for pancreatic diseases. All selected articles were reviewed and analyzed.

RESULTS

If there were no contraindications for LDP, this operation is suitable for benign, borderline, or malignant tumors of the pancreatic body and tail, which should try to be performed with preservation of the spleen. LDP is safe and feasible under some conditions to experienced surgeon. Single-incision laparoscopic distal pancreatectomy (S-LDP) and robotic laparoscopic distal pancreatectomy (R-LDP) perioperative outcomes are similar with conventional multi-incision laparoscopic distal pancreatectomy (C-LDP). And the advantages of S-LDP and R-LDP require further exploration. With the application of enhanced recovery program (ERP), length of hospital stay and costs are reduced.

CONCLUSIONS

LDP is safe and feasible under some conditions. Compared with open distal pancreatectomy, LDP has a lot of advantages; a trend was observed for LDP to replace traditional open surgery. LDP combined with ERP is expected to become standard in the treatment of pancreatic body and tail lesions.

Quality and Safety in Health Care, Part XVIII: Improving Outcomes in Colorectal Surgery

An important way to improve outcomes after colorectal surgery is to follow the recommendations of the enhanced recovery pathway after surgery (ERAS). The ERAS guidelines are recommendations that address certain aspects of what should be done before surgery, in the operating room, and following surgery. There is a substantial fall in complications and a decrease in the length of stay for the patient if the recommendations are followed. Elements of the ERAS program are now being adopted for other surgical procedures besides colorectal surgery.

Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter

Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.

Implementation of enhanced recovery programme for laparoscopic distal pancreatectomy: feasibility, safety and cost analysis

BACKGROUND/OBJECTIVES

The adoption of laparoscopy for distal pancreatectomy has proven to substantially improve short-term outcomes. Stress response after major surgery can be further minimized within an enhanced recovery programme (ERP). However, data on the potential benefit of an ERP for laparoscopic distal pancreatectomy are still lacking. The aim was to assess the feasibility, safety and cost of ERP for patients undergoing laparoscopic distal pancreatectomy.

METHODS

This is a case-control study from a Tertiary University Hospital. Sixty-six consecutive patients who underwent laparoscopic distal pancreatectomy were analyzed. Twenty-two patients were enrolled for the ERP and compared with previous consecutive 44 patients managed traditionally (1:2 ratio). Operative details, post-operative outcome and cost analysis were compared in the two groups.

RESULTS

Patients enrolled in the ERP had similar intraoperative blood loss (median 165 ml vs. 200 ml; p = 0.176), operation time (225 min vs. 210 min; p = 0.633), time to remove naso-gastric tube (1 vs. 1 day; p = 0.081) but significantly shorter time to mobilization (median 1 vs. 2 days; p = 0.0001), start solid diet (2 vs. 3 days; p = 0004), and pass stools (3 vs. 5 days; p = 0.002) compared to the control group. Median length of stay was significantly shorter in the ERP group (3 vs. 6 days; p < 0.0001). No significant difference in readmission or complication rate was observed. Cost analysis was significantly in favor of the ERP group (p = 0.0004).

CONCLUSIONS

Implementation of ERP optimizes outcomes for laparoscopic distal pancreatectomy with significant earlier return to normal gut function, reduced length of stay and cost saving.

[Accelerated postoperative rehabilitation: multidisciplinary issue. Part 2]

AIM

To discuss the main aspects of multimodal method of accelerated postoperative rehabilitation (fast track surgery).

MATERIAL AND METHODS

The program of accelerated rehabilitation consists of minimization of surgical treatment's stressful influence on patient's organism in all stages of perioperative period. The method implies use of efficient preoperative management, minimally invasive operations, regional anesthesia and short-acting anesthetics, early postoperative rehabilitation.

RESULTS

The program improves the results of surgical treatment, reduces number of complications and cost of treatment, improves the "quality" of hospital stay and satisfaction of meeting with doctors.