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Patel J, Tolppa T, Biccard BM, Fazzini B, Haniffa R, Marletta D, Moonesinghe R, Pearse R, Vengadasalam S, Stephens TJ, Vindrola-Padros C. Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis. World J Surg 2022; 46:2102-2113. [PMID: 35731268 PMCID: PMC9334384 DOI: 10.1007/s00268-022-06621-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher. METHODS Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation. RESULTS Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources. CONCLUSIONS Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.
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Affiliation(s)
- Jignesh Patel
- Division of Surgery and Interventional Science, Centre for Perioperative Medicine, University College London, London, UK
| | - Timo Tolppa
- Network for Improving Critical Care Systems and Training, YMBA Building, Colombo, 08, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Brigitta Fazzini
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, YMBA Building, Colombo, 08, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | | | - Ramani Moonesinghe
- Division of Surgery and Interventional Science, Centre for Perioperative Medicine, University College London, London, UK
| | - Rupert Pearse
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, c/o ACCU Research Team, Royal London Hospital, Queen Mary University of London, London, E1 1BB, UK
| | | | - Timothy J Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, c/o ACCU Research Team, Royal London Hospital, Queen Mary University of London, London, E1 1BB, UK.
| | - Cecilia Vindrola-Padros
- Division of Surgery, Department of Targeted Intervention, University College London, London, UK
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Singh R, Gupta A, Gupta N, Kumar V. Enhanced recovery after surgery (ERAS): Are anaesthesiologists prepared for the paradigm shift in perioperative care? A prospective cross-sectional survey in India. Indian J Anaesth 2021; 65:S127-S138. [PMID: 34703058 PMCID: PMC8500193 DOI: 10.4103/ija.ija_122_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/10/2021] [Accepted: 04/27/2021] [Indexed: 01/14/2023] Open
Affiliation(s)
- Ruchi Singh
- Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR. BRAIRCH, AIIMS, New Delhi, India
| | - Anju Gupta
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR. BRAIRCH, AIIMS, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR. BRAIRCH, AIIMS, New Delhi, India
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Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis. World J Surg 2021; 45:3249-3257. [PMID: 34365531 PMCID: PMC8476461 DOI: 10.1007/s00268-021-06220-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
Background Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery. Methods ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann–Whitney Fisher’s exact T test or Pearson Chi-square test) was used. Results Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (−€2 356), intensive or intermediate care (−€8 629), medication (−€1 196)), physiotherapy (−€611), laboratory (−€1 625)) and blood transfusion (−€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group. Conclusion ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery.
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Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: A systematic review and meta-analysis. Surgery 2020; 167:540-549. [DOI: 10.1016/j.surg.2019.07.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/15/2019] [Accepted: 07/29/2019] [Indexed: 12/26/2022]
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Krishna Prasad GV. Post-operative analgesia techniques after total knee arthroplasty: A narrative review. Saudi J Anaesth 2020; 14:85-90. [PMID: 31998025 PMCID: PMC6970359 DOI: 10.4103/sja.sja_494_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 09/02/2019] [Indexed: 02/06/2023] Open
Abstract
Post-operative knee pain management has become a challenge to provide early relief and pain-free postoperative care to the patient. The major objectives of post-operative analgesic treatment are to reduce opioid requirements, post-operative pain, and adverse events related to opioid intake. This narrative review aimed to document post-operative analgesia techniques after total knee arthroplasty (TKA). The traditional approach involved high-dose opioid-based regimen, though opioid is considered strong analgesic, but are associated with a number of unwanted side effects to seek for alternative techniques. The role of sciatic nerve block in TKA pain is doubtful. Femoral Nerve Block (FNB) is still considered as the gold standard; however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback more distal nerve block techniques has evolved, namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well-delivered regional nerve blocks and postoperative physical therapy are an essential component which not only minimize the side effects of traditional opioid-based analgesia but also speed up functional recovery, increases patient satisfaction, and reduces the overall length of hospitalization and cost.
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Nakagawa M, Tokunaga M, Aburatani T, Sato Y, Matsuyama T, Nakajima Y, Kinugasa Y. Feasibility and Safety of Early Oral Intake and Discharge After Total or Proximal Gastrectomy: An Analysis of Consecutive Cases Without Exclusion Criteria. Ann Surg Oncol 2019; 27:812-821. [DOI: 10.1245/s10434-019-08072-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 12/13/2022]
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Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials. Gastric Cancer 2019; 22:423-434. [PMID: 30805742 DOI: 10.1007/s10120-019-00937-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain. METHODS A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888). RESULTS Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI - 3.06 to - 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI - 1.02 to - 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively. CONCLUSION Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.
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Shah SB, Hariharan U, Chawla R. Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review. Indian J Anaesth 2019; 63:338-349. [PMID: 31142876 PMCID: PMC6530285 DOI: 10.4103/0019-5049.258058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.
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Affiliation(s)
- SB Shah
- Department of Anaesthesia and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - U Hariharan
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | - R Chawla
- Department of Anaesthesia and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
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Kamarajah SK, Bundred J, Tan BHL. Body composition assessment and sarcopenia in patients with gastric cancer: a systematic review and meta-analysis. Gastric Cancer 2019; 22:10-22. [PMID: 30276574 DOI: 10.1007/s10120-018-0882-2] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION There has recently been increased interest in the assessment of body composition in patients with gastric cancer for the purpose of prognostication. This systematic review and meta-analysis aim to evaluate the current literature on body composition assessment in patients with gastric cancer and its impact on peri-operative outcomes. METHODS A systematic literature search was conducted for studies reporting assessment of body composition in patients with gastric cancers. Meta-analysis of postoperative outcomes (overall and major complications, anastomotic leaks, pulmonary complications) and survival was performed using random effects models. RESULTS Thirty-nine studies reported the assessment of body composition in 8402 patients. Methods used to assess body composition in patients with gastric cancers were computerized tomography (n = 26), bioelectrical impedance analysis (n = 9), and dual-energy-X-ray-absorptiometry (n = 3). Only 21 studies reported the impact of pre-operative sarcopenia on post-operative outcomes. Sarcopenic patients have significantly higher rates of postoperative major complications (n = 12, OR 1.67, CI95% 1.14-2.46, p = 0.009), and pulmonary (n = 8, OR 4.01, CI95% 2.23-7.21, p < 0.001) complications after gastrectomy. Meta-analysis of nine studies reporting overall survival after gastrectomy identified significantly worse survival in patients with pre-operative sarcopenia (HR 2.12, CI95% 1.89-2.38, p < 0.001). CONCLUSIONS Assessment of body composition has the potential to become a clinically useful tool that could support decision-making in patients with gastric cancer. However, variation in methods of assessing and reporting body composition in this patient group limits assessment of current post-operative outcomes.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Bundred
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Benjamin H L Tan
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
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Abstract
Bedside nurses require excellent observational and assessment skills. Being knowledgeable about common diseases that often affect the population is essential; however, it is often more challenging to be informed about life-threatening conditions that rarely develop. Such is the case with mesenteric ischemia, a rare but complicated condition, which is difficult to diagnose, carries a degree of mortality of about 40%-70%, and is more common in people older than 50 years. Mesenteric ischemia requires that nurses be aware of the different etiologies and presentations of this uncommon disease to alert physicians of changes in a patient's condition and detect clues that may assist with an accurate and prompt diagnosis. Being educated about the diagnostic procedures, possible outcomes, and anticipated care and needs of patients affected by this medical complication is imperative to maintain the health status and well-being of these patients and their families.
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Affiliation(s)
- Jose Canceco
- Jose Canceco, BSN, RN, Adult Gerontology Acute Care Nurse Practitioner Program, California State University, Los Angeles. Elizabeth J. Winokur, PhD, RN, CEN, Adult Gerontology Acute Care Nurse Practitioner Program, California State University, Los Angeles
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Li Z, Zhao Q, Bai B, Ji G, Liu Y. Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2018; 42:3463-3473. [PMID: 29750324 DOI: 10.1007/s00268-018-4656-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery. METHODS We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria. RESULTS In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups. CONCLUSIONS ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.
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Affiliation(s)
- Zhengyan Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Gang Ji
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Yezhou Liu
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
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Siotos C, Stergios K, Naska A, Frountzas M, Pergialiotis V, Perrea DN, Nikiteas N. The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies. Surgeon 2018; 16:183-192. [PMID: 29337046 DOI: 10.1016/j.surge.2017.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fast track surgery has been implemented in colorectal procedures during the last decade and is accompanied by significant improvement in patient outcomes during the early postoperative period. However, to date, its adoption in upper gastrointestinal surgery remains a matter of debate. In this context, we aimed to summarize the existing evidence in the international literature. MATERIALS AND METHODS We searched Medline, Scopus, ClinicalTrials.gov and Cochrane Central Register databases for published randomized controlled trials. The meta-analysis was performed with the RevMan 5.3.5 software. MAIN FINDINGS Thirty studies were finally included in the present meta-analysis. The post-operative morbidity was not influenced by the implementation of fast track surgery (FTS) (OR 0.84, 95% CI 0.64-1.09). However, in cases treated with laparoscopic surgery fast track surgery seemed to reduce morbidity by 50% (p = .006). The overall mortality of patients was low in the majority of included studies and was not influenced by fast track surgery (OR 1.12, 95% CI 0.50-2.52). The duration of postoperative hospitalization was significantly reduced with the adoption of FTS (MD -2.24, 95% CI -2.63 to -1.85 days). Concurrently, the overall cost was significantly reduced in cases treated with FTS (MD -982.30, 95% CI -1367.68 to -596.91 U.S dollars). CONCLUSION According to the findings of our meta-analysis suggest that FTS seems to be safe in patients undergoing upper gastrointestinal surgery and reduce both the days of postoperative hospitalization and the overall cost. This observation should be taken into account in future recommendations to enhance the implementation of FTS protocols in current clinical practice.
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Affiliation(s)
- Charalampos Siotos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stergios
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of General Surgery, Watford General Hospital - West Hertfordshire Hospitals NHS Trust, UK.
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, WHO Collaborating Center for Food and Nutrition Policies, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Nikiteas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery. Ann Surg 2017; 267:57-65. [PMID: 28437313 DOI: 10.1097/sla.0000000000002267] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures. BACKGROUND ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols. METHODS A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs. RESULTS A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis. CONCLUSIONS ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.
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Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery. World J Surg 2017; 40:2441-50. [PMID: 27283186 DOI: 10.1007/s00268-016-3582-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery. METHODS A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed. RESULTS Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation. CONCLUSIONS ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.
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Nanavati AJ, Nagral S. Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery? J Minim Access Surg 2016; 12:299-301. [PMID: 27279409 PMCID: PMC4916764 DOI: 10.4103/0972-9941.181392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.
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Affiliation(s)
- Aditya J Nanavati
- Department of General Surgery, Suchak Hospital, Mumbai, Maharashtra, India
| | - Sanjay Nagral
- Department of General Surgery, KB Bhabha Hospital, Mumbai, Maharashtra, India
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Bond‐Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database Syst Rev 2016; 2:CD011382. [PMID: 26829903 PMCID: PMC8765738 DOI: 10.1002/14651858.cd011382.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND 'Fast-track surgery' or 'enhanced recovery protocol' or 'fast-track rehabilitation', incorporating one or more elements of preoperative education, pain relief, early mobilisation, enteral nutrition and growth factors, may improve health-related quality of life and reduce length of hospital stay and costs. The role of enhanced recovery protocols in major upper gastrointestinal, liver and pancreatic surgery is unclear. OBJECTIVES To assess the benefits and harms of enhanced recovery protocols compared with standard care (or usual practice) in major upper gastrointestinal, liver and pancreatic surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until March 2015 to identify randomised trials. We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered only randomised controlled trials (RCTs) performed in people undergoing major upper gastrointestinal, liver and pancreatic surgery, irrespective of language, blinding or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CIs) using both fixed-effect and random-effects models using Review Manager 5, based on available case analysis. MAIN RESULTS Ten studies met the inclusion criteria for the review, and nine studies provided information on one or more outcomes for the review. A total of 1014 participants were randomly assigned to the enhanced recovery protocol (499 participants) or standard care (515 participants) in the nine RCTs. Most of the trials included low anaesthetic risk participants with high performance status undergoing different upper gastrointestinal, liver and pancreatic surgeries. Eight trials incorporated more than one element of the enhanced recovery protocol. All of the trials were at high risk of bias. The overall quality of evidence was low or very low.None of the trials reported long-term mortality, medium-term health-related quality of life(three months to one year), time to return to normal activity, or time to return to work. The difference between the enhanced recovery protocol and standard care were imprecise for short-term mortality (enhanced recovery protocol: 4/425 (adjusted proportion = 0.6%); standard care: 1/443 (0.2%); seven trials; 868 participants; RR 2.79; 95% CI 0.44 to 17.73; very low quality evidence), proportion of people with serious adverse events (enhanced recovery protocol: 4/157 (adjusted proportion = 0.6%); standard care: 0/184 (0.0%); two trials; 341 participants; RR 5.57; 95% CI 0.68 to 45.89; very low quality evidence), number of serious adverse events (enhanced recovery protocol: 34/421 (8 per 100 participants); standard care: 46/438 (11 per 100 participants); seven trials; 859 participants; rate ratio 0.72; 95% CI 0.45 to 1.13; very low quality evidence), health-related quality of life (four trials; 373 participants; SMD 0.29; 95% CI -0.04 to 0.62; very low quality evidence) and hospital readmissions (enhanced recovery protocol: 14/355 (adjusted proportion = 3.3%); standard care: 9/378 (2.4%); seven trials; 733 participants; RR 1.4; 95% CI 0.69 to 2.87; very low quality evidence). The enhanced recovery protocol group had a lower proportion of people with mild adverse events (enhanced recovery protocol: 31/254 (adjusted proportion = 10.9%); standard care: 51/271 (18.8%); four trials; 525 participants; RR 0.58; 95% CI 0.39 to 0.85; low quality evidence), fewer number of mild adverse events (enhanced recovery protocol: 69/499 (13 per 100 participants); standard care: 128/515 (25 per 100 participants); nine trials; 1014 participants; rate ratio 0.52; 95% CI 0.39 to 0.70; low quality evidence), shorter length of hospital stay (nine trials; 1014 participants; MD -2.19 days; 95% CI -2.53 to -1.85; low quality evidence) and lower costs (four trials; 282 participants; MD USD -6300; 95% CI -8400 to -4200; low quality evidence) than standard care group. AUTHORS' CONCLUSIONS Based on low quality evidence, enhanced recovery protocols may reduce length of hospital stay and costs (primarily because of reduction in hospital stay) in people undergoing major upper gastrointestinal, liver and pancreatic surgeries. However, the validity of the results is uncertain because of the risk of bias in the trials and the way the outcomes were measured. Future RCTs should be conducted with low risk of bias, and measure clinically important outcomes for including the three months to one year period.
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Affiliation(s)
- Giles Bond‐Smith
- Churchill HospitalDepartment of Hepatobiliary SurgeryOxfordUKOx3 7L3
| | - Ajay P Belgaumkar
- Royal Free London NHS Foundation TrustHPB and Liver Transplant Surgery, 8 SouthPond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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Joliat GR, Labgaa I, Petermann D, Hübner M, Griesser AC, Demartines N, Schäfer M. Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy. Br J Surg 2015; 102:1676-83. [PMID: 26492489 DOI: 10.1002/bjs.9957] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/04/2015] [Accepted: 08/28/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy. METHODS ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model. RESULTS The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151). CONCLUSION ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.
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Affiliation(s)
- G-R Joliat
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - I Labgaa
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - D Petermann
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - M Hübner
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - A-C Griesser
- Medical Directorate, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - N Demartines
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - M Schäfer
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
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Inokuchi M, Otsuki S, Fujimori Y, Sato Y, Nakagawa M, Kojima K. Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy. World J Gastroenterol 2015; 21:9656-9665. [PMID: 26327774 PMCID: PMC4548127 DOI: 10.3748/wjg.v21.i32.9656] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/02/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the anastomotic complications of esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG), we reviewed retrospective studies.
METHODS: A literature search was conducted in PubMed for studies published from January 1, 1994 through January 31, 2015. The search terms included “laparoscopic,”“total gastrectomy,” and “gastric cancer.” First, we selected 16 non-randomized controlled trials (RCTs) comparing LTG with open total gastrectomy (OTG) and conducted an updated meta-analysis of anastomotic complications after total gastrectomy. The Newcastle-Ottawa scoring system (NOS) was used to assess the quality of the non-RCTs included in this study. Next, we reviewed anastomotic complications in 46 case studies of LTG to compare the various procedures for EJS.
RESULTS: The overall incidence of anastomotic leakage associated with EJS was 3.0% (30 of 984 patients) among LTG procedures and 2.1% (31 of 1500 patients) among OTG procedures in the 16 non-RCTs. The incidence of anastomotic leakage did not differ significantly between LTG and OTG (odds OR = 1.42, 95%CI: 0.86-2.33, P = 0.17, I2 = 0%). Anastomotic stenosis related to EJS was reported in 72 (2.9%) of 2484 patients, and the incidence was 3.2% among LTG procedures and 2.7% among OTG procedures. The incidence of anastomotic stenosis related to EJS was slightly, but not significantly, higher in LTG than in OTG (OR = 1.55, 95%CI: 0.94-2.54, P = 0.08, I2 = 0%). The various procedures for LTG were classified into six categories in the review of case studies of LTG. The incidence of EJS leakage was similar (1.1% to 3.2%), although the incidence of EJS stenosis was relatively high when the OrVilTM device was used (8.8%) compared with other procedures (1.0% to 3.6%).
CONCLUSION: The incidence of anastomotic complications associated with EJS was not different between LTG and OTG. Anastomotic stenosis was relatively common when the OrVilTM device was used.
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Beamish AJ, Chan DSY, Blake PA, Karran A, Lewis WG. Systematic review and meta-analysis of enhanced recovery programmes in gastric cancer surgery. Int J Surg 2015; 19:46-54. [PMID: 26004350 DOI: 10.1016/j.ijsu.2015.05.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/17/2015] [Accepted: 05/12/2015] [Indexed: 02/07/2023]
Abstract
This systematic review and meta-analysis was performed to determine the influence of enhanced recovery programmes (ERPs) on outcomes after gastric cancer surgery. Medline, Embase, the Cochrane library and ClinicalTrials.gov were searched for studies on outcomes of gastrectomy in enhanced recovery or fast-track programmes. The primary outcome measure was post-operative duration of hospital stay (LOHS), and secondary outcome measures were selected based inclusion in two or more studies. Statistical analysis was performed using standardized mean difference (SMD) and odds ratio (OR) as the summary statistics. Fourteen studies, totalling 1676 patients with gastric cancer were analysed, including nine randomized trials. LOHS was significantly shorter after ERP when compared with control patients (CON, SMD -1.10, 95% confidence interval -1.56 to -0.65, p < 0.001), but with significant heterogeneity between studies (I(2) = 93%, p < 0.001). ERP was also associated with reduced serum inflammatory response (CRP: SMD -0.68 (-1.16 to -0.19), p = 0.007; IL-6: SMD -0.62 (-0.94 to -0.29), p < 0.001), less weight loss (SMD -0.79 (-1.11 to -0.46), p < 0.001), and lower cost (SMD -1.02 (-1.59 to -0.45), p < 0.001), as well as a trend toward shorter duration of intravenous infusion (SMD -2.70 (-5.35 to -0.05), p = 0.05). Inclusion in an ERP was not associated with increased post-operative morbidity (OR 0.83 (0.65 to 1.06), p = 0.13) or hospital readmission (OR 1.67 (0.88 to 3.19), p = 0.12). From this review the authors concluded that multimodal, standardized perioperative gastrectomy care appears feasible, safe and cost effective.
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Affiliation(s)
- Andrew James Beamish
- Department of General Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - David Sheng Yi Chan
- Department of General Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Paul A Blake
- Department of General Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Alexandra Karran
- Department of General Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Wyn Griffith Lewis
- Department of General Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK.
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Nanavati AJ. ERAS in laparoscopic-assisted total gastrectomy. J Minim Access Surg 2015; 11:165. [PMID: 25883463 PMCID: PMC4392496 DOI: 10.4103/0972-9941.142402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aditya J Nanavati
- Specialty Medical Officer, Department of Surgery, K.B. Bhabha Hospital, Bandra West, Mumbai, Maharashtra, India
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Shrikhande SV, Pai E. Enhanced recovery after surgery in laparoscopic gastric cancer surgery: Many questions, few answers. J Minim Access Surg 2014; 10:105-6. [PMID: 25013324 PMCID: PMC4083540 DOI: 10.4103/0972-9941.134871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Shailesh V Shrikhande
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, GI Disease Management Group, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra, India. E-mail:
| | - Esha Pai
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, GI Disease Management Group, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra, India. E-mail:
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