Enhanced recovery protocol in esophagectomy, is it really worth it? A cost analysis related to team experience and protocol compliance

Application of enhanced recovery protocols (ERP) in esophageal surgery seems to lead an advantage in terms of length of hospital staying and outcomes, but only few data exist on its cost effectiveness. Previous literature analyzed pre- and post-ERP groups, finding a cost reduction with the introduction of the pathway. We aimed to study the influence on costs of accumulating experience and compliance in an ERP group. Seventy-one patients have been treated at our institution from January 2014 to June 2017 with our ERP for Ivor-Lewis esophagectomy. Direct costs were divided into subcategories and were analyzed as a function of calendar year and compliance. Factor affecting costs were searched. Univariable analysis highlighted a significant reduction in costs over time. Increase in compliance led to a progressive cost reduction for each ERP item completed (€14 852-€11 045). While age was not found to significantly influence the cost (p = 0.341), complications seemed to nullify the effect of experience: the median was €11 507 in uncomplicated patients, and increased to €13 791 in Clavien-Dindo 3-4 (CD3-4) patients. Compliance and CD3-4 remained significant also in multivariable analysis, accomplished by quantile regression, while year of surgery lost its significance. Our results evidence how accumulating experience in ERP led to a cost reduction over time, which was mainly mediated by an increase in compliance. Indeed, compliance was the main factor in reducing ERP cost while CD3-4 complications were the most important factor in cost increasing, nullifying the benefit of compliance.

Enhanced recovery after surgery protocol in patients undergoing esophagectomy for cancer: a single center experience

This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.

Effects of experimentally induced ametropia on the morphology and optical quality of the avian crystalline lens

PURPOSE

To examine the effects of refractive error on avian lens morphology and optical quality.

METHODS

Hatchling white leghorn chicks were unilaterally goggled for 7 days with either a form-deprivation goggle (n = 12), a -10 D defocus goggle (n = 12), or a +10 D defocus goggle (n = 12) to induce myopia and hyperopia. Optical quality of lenses (focal length and focal length variability) from treated and contralateral control eyes was assessed using a scanning laser apparatus. Lens morphology was examined by light and electron microscopy.

RESULTS

Although the induction of refractive errors did not significantly alter lens size, shape, paraxial focal length, or average focal length, average focal length variability increased. Lenses from eyes goggled with form-deprivation and +10 D defocus goggles demonstrated a twofold increase in average focal length variability, when compared with their contralateral controls. The morphology of the lens is not altered by these experimental manipulations.

CONCLUSIONS

This study provides evidence that the refractive development of the chick lens is not independent of the refractive development of the ocular globe and that chick lenticular development is influenced by both genetics and visual experience.

Effect of age on the morphology and optical quality of the avian crystalline lens

The effect of age on the avian lens was examined using White Leghorn chickens of five age groups: hatchling (n =19), 7 day (n = 15), 34 week (n =10), 2 year (n =24), and 5 year (n =25). The chick lens grows steadily up to 34 weeks of age, after which, the rate of growth slows down. During growth, average focal length of the lens becomes longer. However, no significant changes were noted between 2 and 5 year old lenses. An age related increase in average lenticular focal length variability (FLV) was observed, revealing that the optical quality of the lens decreases with age. Scanning electron microscopy demonstrated that: (1) the suture region of the lens becomes more diffuse and less precise with age; (2) the central regions of younger lenses are oblate spheroids, while older lenses become more apple-shaped; (3) individual lens fibres in the young lens are crescent-shaped, while older lens fibres are square-bracket-like in shape; (4) the edges of individual lens fibres become more jagged and irregular with age; and (5) the layering of lens fibres is more disorderly in older lenses, in contrast to the parallel and organized layering of fibres in young lenses.

Relating clinical study design to basic research

Devising any research study involves careful attention to its design, as well as the development of an appropriate research question and hypothesis. Together, these attributes ensure the validity of the study in question. In most clinical or epidemiological studies, the types of research designs are often explicitly noted, whereas in papers describing basic or biological research, they are couched in different terms or, more often, are ignored, thus potentially hindering communication between basic and clinical researchers. However, given that the framework for all valid scientific research is based on sound logic, it is proposed that for each study design, a direct homology exists between clinical and basic research paradigms, despite the problem of relating epidemiological vernacular to basic research. By applying examples of basic research protocols to traditional clinical study designs, this paper shows that parallels can be drawn between the two strategies, suggesting that in the absence of a conventional nomenclature to describe basic research study designs, the use of traditional clinical design jargon is valid in describing basic research protocols.