1
|
Vandervelde CM, Everaerts S, Weder W, Orolé S, Hermans PJ, De Leyn P, Nafteux P, Decaluwé H, Van Veer H, Depypere L, Coppens S, Neyrinck AP, Bouneb S, De Coster J, Coolen J, Dooms C, Van Raemdonck DE, Janssens W, Ceulemans LJ. Implementation of an enhanced recovery protocol for lung volume reduction surgery: an observational cohort study. Eur J Cardiothorac Surg 2024; 65:ezae109. [PMID: 38507704 DOI: 10.1093/ejcts/ezae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP. METHODS This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS. RESULTS Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l). CONCLUSIONS Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months.
Collapse
Affiliation(s)
- Christelle M Vandervelde
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Stephanie Everaerts
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Walter Weder
- Department of Thoracic Surgery, Klinik Bethanien, Zurich, Switzerland
| | - Siebe Orolé
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pieter-Jan Hermans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Herbert Decaluwé
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Division of Anesthesiology and Algology, KU Leuven, Leuven, Belgium
| | - Arne P Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Division of Anesthesiology and Algology, KU Leuven, Leuven, Belgium
| | - Sofian Bouneb
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Division of Anesthesiology and Algology, KU Leuven, Leuven, Belgium
| | - Johan De Coster
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Division of Anesthesiology and Algology, KU Leuven, Leuven, Belgium
| | - Johan Coolen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Dooms
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Wim Janssens
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Pneumology and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Langouche L, Téblick A, Gunst J, Van den Berghe G. The Hypothalamus-pituitary-adrenocortical Response to Critical Illness: A Concept in Need of Revision. Endocr Rev 2023; 44:1096-1106. [PMID: 37409973 PMCID: PMC10638597 DOI: 10.1210/endrev/bnad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
Based on insights obtained during the past decade, the classical concept of an activated hypothalamus-pituitary-adrenocortical axis in response to critical illness is in need of revision. After a brief central hypothalamus-pituitary-adrenocortical axis activation, the vital maintenance of increased systemic cortisol availability and action in response to critical illness is predominantly driven by peripheral adaptations rather than by an ongoing centrally activated several-fold increased production and secretion of cortisol. Besides the known reduction of cortisol-binding proteins that increases free cortisol, these peripheral responses comprise suppressed cortisol metabolism in liver and kidney, prolonging cortisol half-life, and local alterations in expression of 11βHSD1, glucocorticoid receptor-α (GRα), and FK506 binding protein 5 (FKBP51) that appear to titrate increased GRα action in vital organs and tissues while reducing GRα action in neutrophils, possibly preventing immune-suppressive off-target effects of increased systemic cortisol availability. Peripherally increased cortisol exerts negative feed-back inhibition at the pituitary level impairing processing of pro-opiomelanocortin into ACTH, thereby reducing ACTH-driven cortisol secretion, whereas ongoing central activation results in increased circulating pro-opiomelanocortin. These alterations seem adaptive and beneficial for the host in the short term. However, as a consequence, patients with prolonged critical illness who require intensive care for weeks or longer may develop a form of central adrenal insufficiency. The new findings supersede earlier concepts such as "relative," as opposed to "absolute," adrenal insufficiency and generalized systemic glucocorticoid resistance in the critically ill. The findings also question the scientific basis for broad implementation of stress dose hydrocortisone treatment of patients suffering from acute septic shock solely based on assumption of cortisol insufficiency.
Collapse
Affiliation(s)
- Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| |
Collapse
|
3
|
Canovai E, Farré R, Accarie A, Lauriola M, De Hertogh G, Vanuytsel T, Pirenne J, Ceulemans LJ. INT-767-A Dual Farnesoid-X Receptor (FXR) and Takeda G Protein-Coupled Receptor-5 (TGR5) Agonist Improves Survival in Rats and Attenuates Intestinal Ischemia Reperfusion Injury. Int J Mol Sci 2023; 24:14881. [PMID: 37834329 PMCID: PMC10573246 DOI: 10.3390/ijms241914881] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Intestinal ischemia is a potentially catastrophic emergency, with a high rate of morbidity and mortality. Currently, no specific pharmacological treatments are available. Previous work demonstrated that pre-treatment with obeticholic acid (OCA) protected against ischemia reperfusion injury (IRI). Recently, a more potent and water-soluble version has been synthesized: Intercept 767 (INT-767). The aim of this study was to investigate if intravenous treatment with INT-767 can improve outcomes after IRI. In a validated rat model of IRI (60 min ischemia + 60 min reperfusion), three groups were investigated (n = 6/group): (i) sham: surgery without ischemia; (ii) IRI + vehicle; and (iii) IRI + INT-767. The vehicle (0.9% NaCl) or INT-767 (10 mg/kg) were administered intravenously 15 min after start of ischemia. Endpoints were 7-day survival, serum injury markers (L-lactate and I-FABP), histology (Park-Chiu and villus length), permeability (transepithelial electrical resistance and endotoxin translocation), and cytokine expression. Untreated, IRI was uniformly lethal by provoking severe inflammation and structural damage, leading to translocation and sepsis. INT-767 treatment significantly improved survival by reducing inflammation and preserving intestinal structural integrity. This study demonstrates that treatment with INT-767 15 min after onset of intestinal ischemia significantly decreases IRI and improves survival. The ability to administer INT-767 intravenously greatly enhances its clinical potential.
Collapse
Affiliation(s)
- Emilio Canovai
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, 3000 Leuven, Belgium (T.V.); (L.J.C.)
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Ricard Farré
- Translation Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Alison Accarie
- Translation Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Mara Lauriola
- Translation Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Laboratory of Nephrology and Renal Transplantation, Department of Microbiology, Immunology, and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Gert De Hertogh
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, 3000 Leuven, Belgium (T.V.); (L.J.C.)
- Translational Cell and Tissue Research, Department of Imaging & Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Tim Vanuytsel
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, 3000 Leuven, Belgium (T.V.); (L.J.C.)
- Translation Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Gastroenterology and Hepatology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, 3000 Leuven, Belgium (T.V.); (L.J.C.)
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Laurens J. Ceulemans
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, 3000 Leuven, Belgium (T.V.); (L.J.C.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| |
Collapse
|