[ERAS, from concept to care]

Enhanced recovery after surgery (ERAS) aims at reducing the length of hospital stays and complications. Everyone has a role to play - healthcare professionals, medical secretaries, administrative staff and patients. A coordinated treatment pathway must be ensured and changes in practices must be accepted.

Large-scale implementation of enhanced recovery programs after surgery. A francophone experience

INTRODUCTION

Enhanced recovery after surgery program (ERP) has now surpassed the stage of clinical research in certain specialties and currently poses the problematic of large-scale implementation. The goal of this study was to report the experience during the first year of implementation in three French-speaking countries.

MATERIAL AND METHODS

This is a prospective study in which 67 healthcare centers, all registered in the Grace-Audit databank, participated. Included were patients undergoing colorectal (CRS), bariatric (BS) and orthopedic hip and knee surgery (OS), performed within an ERP. The main endpoints were duration of hospital stay, postoperative morbidity, the degree of compliance with the elements of the ERP, the relation between the extent of application of the elements and postoperative hospital stay, and finally the completeness of data inclusions in the databank.

RESULTS

A total of 1904 patients were included in the Grace-Audit databank between January 1, 2015 and January 31, 2016, undergoing CRS (n=490), BS (n=431), and OS (n=983). The mean implementation rate was 83.7±10.0% for CRS, 75.0±23.7% for BS, and 83.5±14.9% for OS. The duration of hospital stay was 6.5 days for CRS, 2.6 days for BS and 3.4 days for OS. Overall postoperative morbidity (onset of postoperative undesirable event), surgical morbidity (superficial or deep organ space surgical site complications such as bleeding, infection or defective healing) and readmission rates were 20.6%, 7.5%, and 5.7% for CRS; 2.5%, 1.4%, and 1.6% for BS and 2.9%, 0.2%, and 2% for OS, respectively. A statistically significant relationship was found between the degree of compliance of the elements of ERP and the duration of hospital stay for CRS and BS; hospital stay was reduced when at least 15 of the 22 elements of the program were applied (P<0.001). The patients included in the Grace-Audit databank represented less than 20% of the patients undergoing operation in the same establishments during the study period for all three specialties.

CONCLUSIONS

This study shows that large-scale ERPs are feasible and safe in French-speaking countries. Nonetheless, although encouraging, these preliminary results highlight that implementation must be improved in specialties such as bariatric surgery and that more complete data collection is needed.

[Malignant transformation of multiple isolated hepatocellular adenomas. Therapeutic implications of immunohistochemical and radiological findings]

Malignant transformation of hepatic adenoma (HA) is now a well-documented phenomenon. Recent pathological and immunophenotypic studies have identified several subtypes with different prognoses. In many cases the HA subtype can be determined by modern radiological methods, including contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI). Based on a series of 26 cases of HA studied with CEUS, MR1 histopathology and immunochemistry, we propose tailored therapeutic options. Watchful waiting is appropriate in some cases, while others require biopsy or resection. Management is more conservative than in previous years.

Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity

GOAL

Laparoscopic sleeve gastrectomy (LSG) is performed in certain circumstances after failure of gastric banding. The goal of this study was to evaluate the impact of first-line gastric banding on the morbidity associated with secondary LSG for obesity.

PATIENTS AND METHODS

The case records of 102 consecutive patients undergoing LSG were studied retrospectively. The technique of LSG was standardized. Two groups were compared: one with patients having undergone LSG after first-line gastric banding (n = 31) and the second, with patients having undergone first-line LSG (n = 71). Endpoints were overall morbidity and intra/postoperative complications including gastric leaks consecutive to staple line disruption as well as other septic or hemorrhagic complications. Multivariable analysis was performed to detect independent risk factors for morbidity.

RESULTS

Overall morbidity was significantly higher in patients having undergone LSG after first-line gastric banding compared with those undergoing first-line LSG (32.2% vs. 7%, P = 0.002). Gastric leaks secondary to staple line disruption also occurred statistically significantly more often in patients with first-line gastric banding (16.1% vs. 2.8%, P = 0.043). Waiting 6 months between gastric band removal and performing LSG did not prevent the increased morbidity compared with first-line LSG. Multivariable analysis revealed that among the factors analyzed (age, gender, comorbidity, body mass index, surgeon, first-line gastric banding), the only independent risk factor for staple line disruption was first-line gastric banding with an odds ratio = 6.6 (95% confidence interval = [1.2-36.3]).

CONCLUSION

Undergoing first-line gastric banding increases the risk of complications after secondary LSG. We recommend that patients who undergo LSG after a first-line gastric banding should be warned of the increased risks of morbidity or, alternatively, that LSG be performed preferentially as the initial procedure.