Implementation of holistic nursing interventions based on fast track surgery concept in patients with lower extremity arterial occlusive disease

Lower Extremity Arterial Occlusive Disease (LEAOD) is a prevalent condition affecting many patients worldwide, which requires careful management and patient cooperation. This study aimed to evaluate the effectiveness of holistic nursing interventions based on the Fast Track Surgery (FTS) concept in patients with LEAOD. A retrospective analysis of 92 LEAOD patients, randomized into control and experimental groups, was performed. Conventional rehabilitation nursing interventions were applied to the control group, while the experimental group received holistic rehabilitation nursing interventions based on the FTS concept. Patient adherence was assessed before and after the intervention using a hospital survey, and sleep quality was evaluated using the Pittsburgh Sleep Quality Index on days 3, 7, and 15 post-interventions. Post-intervention, the experimental group exhibited significantly improved adherence to balanced diet, regular exercise, timely medication, and regular review visits compared to the control group (P < .05). Further, Pittsburgh Sleep Quality Index scores indicated significantly better sleep quality over time in the experimental group than in the control group (P < .05). The implementation of holistic nursing interventions based on the FTS concept significantly improved patient adherence and sleep quality in LEAOD patients. These findings highlight the potential benefits of integrating such interventions in the management of LEAOD patients, potentially enhancing postoperative recovery and overall health outcomes.

Evaluation of enhanced recovery after surgery for gastric cancer patients undergoing gastrectomy: a systematic review and meta-analysis

Introduction

For complicated surgical patients, enhanced recovery after surgery (ERAS) decreases stress and hospital stays. It accelerates recovery and lowers readmissions, morbidity, and death. ERAS's effectiveness in stomach cancer laparoscopic-assisted gastrectomy (LAG) or robotic gastrectomy is still debated.

Aim

This study assesses the efficacy and safety of the ERAS program for patients undergoing gastrectomy for gastric cancer.

Material and methods

PRISMA-compliant searches were performed in Medline, Embase, PubMed, the Web of Sciences, and the Cochrane Library databases until March 2023. The search included articles that compared ERAS protocol results for gastric cancer surgery patients to conventional care. RevMan performed meta-analysis, and the Cochrane Risk of Bias Assessment Tool assessed study quality.

Results

This meta-analysis contained 11 carefully chosen randomized controlled trials (RCTs) involving 1790 people. The ERAS group had 902 participants, while the traditional care group had 888. The ERAS group had a shorter post-operative hospital stay, with a weighted mean difference (WMD) of -1.12 days (95% CI: -1.89 to -0.35, p = 0.00001), I2 = 89%, and a lower number of patients with post-operative problems, with an odds ratio (OR) of 0.73 (95% CI: 0.55 to 0.97; p = 0.03), I2 = 60%.

Conclusions

The ERAS procedure has been shown to be effective as well as beneficial for patients undergoing either laparoscopic-assisted or robotic gastrectomy for gastric cancer, since it lowers post-operative complications and accelerates recovery with improved results.

An evaluation of the effectiveness and safety of the Enhanced Recovery After Surgery (ERAS) program for patients undergoing colorectal surgery: a meta-analysis of randomized controlled trials

Introduction

The Enhanced Recovery After Surgery (ERAS) protocol reduces surgery-related stress and hospital stays for complicated surgical patients. It speeds recovery, reduces readmissions, and lowers morbidity and mortality. However, the efficacy of ERAS in colorectal surgery is still debatable.

Aim

To evaluate the effectiveness and safety of the ERAS program for patients undergoing colorectal surgery.

Material and methods

PRISMA-compliant searches were performed on Medline, Embase, PubMed, the Web of Sciences, and the Cochrane Database up to March 2023. The included articles compared ERAS protocol results for colorectal surgery patients to those of conventional care. RevMan was used for the meta-analysis, and the Cochrane RoB Tool was used to assess the study quality.

Results

The meta-analysis included 12 randomized controlled trials with a total of 1920 participants. There were 880 individuals in ERAS care and 1002 in conventional care. Weighted mean difference: -1.07 days, 95% confidence interval (CI): -1.53 to -0.60, p = 0.00001), overall length of stay: -4.12 days, 95% CI: -5.86 to -2.38, p = 0.00001), and post-operative hospital stay: -1.91 days, 95% CI: -4.73 to -0.91, p = 0.00001). Readmissions were higher in the ERAS group than in the normal care group (odds ratio (OR) = 1.20, 95% CI: 0.82 to 1.75, p = 0.35). Post-operative complications were lower in the ERAS care group (OR = 0.42; 95% CI: 0.27 to 0.65, p < 0.0001) and SSIs (OR = 0.75; 95% CI 0.52 to 1.08, p = 0.00001) than in the routine care group.

Conclusions

Care provided in line with the ERAS protocol has been shown to be successful and beneficial for patients following colorectal surgery, because it minimizes post-operative problems and length of hospital stay, and improves outcomes.

Nursing measures in the fast-track surgery on negative emotions in breast cancer patients: A meta-analysis

BACKGROUND

To critically evaluate the effects of different nursing measures based on the concept of fast-track surgery (FTS) on the negative emotions of patients with breast cancer.

METHODS

A systematic search of 8 databases, namely PubMed, Cochrane Library, Embase, Psycho info, China national knowledge infrastructure, Wanfang, China science and technology journal database, and China biomedical literature database, was performed to find randomized controlled trials from inception to April 2023. Two reviewers critically and independently assessed the risk of bias using Cochrane Collaboration criteria and extracted correlated data using the designed form. All analyses were performed with Review Manager 5.3.

RESULTS

Ten studies were included in the systematic review, with a total of 830 patients (FTS group: 415; control group: 415). The results showed that different nursing measures based on the concept of FTS could significantly reduce anxiety (MD = -1.74, 95% confidence intervals [-2.41, -1.08], P < .00001) and depression (MD = -1.98, 95% confidence intervals [-2.44, -1.51], P < .00001) in patients after modified breast cancer surgery compared with the control group.

CONCLUSIONS

Based on the concept of FTS, the nursing measures such as reducing preoperative fasting time, posture management, preventive analgesia, and early functional exercise can effectively reduce the anxiety and depression of patients during the perioperative period.

IMPLEMENTATION OF ERAS PROTOCOL FOR CESAREAN SECTION

In the past few decades, many changes have been noticed in all medical branches, especially in surgery. Enhanced Recovery After Surgery (ERAS) is a completely new approach, with the main goal to change the period of patient's recovery, making perioperative time easier and shorter. The patient's recovery is faster, better and the patient's satisfaction is bigger. Patients have an active role in their own recovery, which results in faster return to work and everyday activities. Hospital Length of Stay (LOS) is shorter and associated with concomitant financial savings. After ERAS protocol had been implemented in colorectal, abdominal surgery, urology orthopedic and oncology, and finally in obstetrics for cesarean section as well. This protocol has mostly been used in developed countries, but not in all hospitals. Creation and implementation of ERAS protocol is hard work, which includes multidisciplinary team work and especially a team leader, who coordinates the medical team, the patient and hospital management. Conclusion: Creation of an ERAS protocol is very serious and long- lasting work. It is multidisciplinary and it usually has to be individually tailored for each institution itself in coordination with the health care system and with the final implementation in the medical system.

Enhanced recovery after surgery in children

Enhanced recovery after surgery (ERAS) is a systematic approach to optimize a patient's health and improve clinical outcomes, increase patient satisfaction and decrease healthcare costs. Enhanced recovery protocols have been used across a variety of surgical disciplines and patient groups to improve patient safety and reduce hospital length of stay without increasing return visits to the system. ERAS involves the application of clinical decision making throughout the patient experience with interventions in the preoperative, perioperative and post operative phases. In addition, ERAS is multidisciplinary and the success of an ERAS program is dependent on the effort and integration of stakeholders across the healthcare system. Utilization of ERAS systems have grown across the global adult surgical community over the last three decades and adoption in pediatric surgery has only occurred recently. Hospitals in both adult and pediatric surgery have found that implementation of ERAS systems lead to a shortened length of stay and reduced complications without increasing patient returns to the system. Importantly patients who have surgery within an ERAS program experience less pain, less opioid utilization, a quicker recovery and increased satisfaction. In pediatric surgery ERAS has successfully been employed across most all disciplines from congenital cardiac surgery to colorectal surgery. The evolution of ERAS continues as a paradigm of quality and safety.

Rapid rehabilitation nursing improves clinical outcomes in postoperative patients with colorectal carcinoma: A protocol for randomized controlled trial

BACKGROUND

Colorectal carcinoma has a high incidence rate and the high mortality rate has always been an important global health challenge. Surgical treatment is widely performed in patients with colorectal carcinoma. Fast track surgery (FTS) applies evidence-based medical concept to optimize the management during the operation, so as to reduce the psychological and physical trauma stress of surgical patients and make them recover rapidly. We perform this protocol for randomized controlled study to evaluate the efficacy of a rapid rehabilitation care in colorectal carcinoma surgery.

METHODS

It is a single-center randomized controlled study to be conducted from January 2021 to December 2021. It was authorized via the Ethics Committee of the Huzhou Central Hospital (20191127-01). Eighty participants who undergo colorectal carcinoma surgery will be included in this research. Patients are randomly assigned to control group (standard management group, including 40 samples) and study group (the FTS group, including 40 samples). The main results are times of postoperative exhaust, first defecation, ambulation, first eating, and postoperative hospital stay. Secondary outcomes are incidence of nausea and emesis, wound infection, urinary tract infection, lung infection, deep vein thrombosis, and rehospitalization rate among the 2 groups. All analyses are conducted using the SPSS for Windows Release 15.0.

RESULTS

Figure 1 shows the clinical results between groups.

CONCLUSION

The research can offer a reliable basis for the effectiveness of a rapid recovery nursing program in patients with colorectal carcinoma.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6038).

Survival Advantage of Upfront Surgery for Pancreatic Head Cancer Without Preoperative Biliary Drainage

Introduction

Level 1 evidence from randomized trials demonstrates less complication when jaundiced patients with resectable pancreatic cancer proceed directly to surgery, rather than undergo preoperative biliary drainage (PBD) first. Although "fast track" surgery significantly increases the resectability rate, it is unknown whether this translates into a survival benefit. This study evaluated the effect of upfront surgery on long-term survival using an intention-to-treat (ITT) analysis.

Methods

Patients were identified from a prospectively maintained database, stratified according to whether or not they underwent PBD.

Results

Among 157 patients, 84 (54%) underwent PBD. Of these, 73% underwent surgery, compared to 100% of those without PBD (p<0.001). Reasons for not undergoing surgery were progression of cancer (N=11), progressive frailty (N=5), or PBD-related complication (N=7). In those who underwent surgery, PBD was associated with a longer time from diagnosis to surgery (median: 59 vs. 14 days, p<0.001), and a higher rate of unresectable cancer at surgery (26% vs. 3%, p<0.001). On an ITT basis, patients treated with PBD had significantly shorter survival, at a median of 15 vs. 19 months (HR: 1.59, 95% CI: 1.07-2.37, p=0.023). However, for the subset of patients who underwent resection, survival was similar in the two groups (HR: 1.07, 95% CI: 0.66-1.73, p=0.773).

Conclusions

A reduced time to surgery with avoidance of PBD offers survival benefit. This is only appreciated on ITT analysis, which includes patients who are initially considered candidates for surgery, but ultimately do not undergo surgery. Considering this 'hidden' cohort of patients is important when considering optimal pathways for the treatment of resectable pancreatic cancer.

Orthopedic treatment for open fracture of lower extremities and soft tissue defects in young children and rapid rehabilitation after operation

Objective: This study aims to explore the clinical features of open fracture of lower extremities with soft tissue injury in young children, and its surgical and postoperative rehabilitation methods.Methods: A total of 32 children with open fracture of lower extremities and soft tissue injury treated in our department from January 2010 to December 2016 were included into this study. An individualized treatment plan was established according to the characteristics of each patient's condition, and rapid rehabilitation procedures were carried out after the operation to promote the healing of the wound, and shape and function recovery.Results: In the present study, four children developed superficial infection after the operation, and healed after proper management. Furthermore, two children were found to have osteomyelitis during follow-up after discharge, and healed after they returned to the hospital for debridement. All patients were followed up until fracture healing, and the follow-up duration ranged within 6-15 months, with an average duration of 8.5 months. All patients achieved bony union, and none of the patients had bone exposure. In the curative effect assessment, 24 children were classified as excellent, six children were classified as good, one child was classified as moderate, and one child was classified as poor. The excellent and good rate was 93.75%.Conclusions: Open fracture of the lower extremities commonly occur in the middle and lower segment of the tibia and fibula in children, and is usually combined with soft tissue injury. The correct treatment of fractures, and skin and soft tissue injuries, as well as the rapid rehabilitation of children, are the keys to achieving a good clinical effect.

Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit?

Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.

One-year Unplanned Readmission After Colorectal Cancer Surgery in Western China

Purpose: Readmissions are common after colorectal cancer surgery. There are limited data related one-year unplanned readmission after colorectal cancer surgery. The aim of this study was to ascertain the incidence rate of unplanned readmission in Western China, identify causes and risk factors of one-year unplanned readmission (UR) in patients who underwent enhanced recovery pathways for colorectal cancer (CRC) surgery. Materials and Methods: A retrospective study using a CRC surgery database of patients treated in West China Hospital was performed. Patients who underwent enhanced recovery pathways for colorectal cancer surgery between January 2013 and May 2016 were investigated. The postoperative follow-up data were all routinely recorded for up to one year or more, the one-year unplanned readmission rate after initial discharge and major reasons for UR were recorded. Multivariate logistic regression analyses was used to identify risk factors of UR. Results: A total of 446 patients were included, with 18.6% of patients readmitted. In a multivariable analysis, preoperative comorbidity was associated with the largest risk of readmission (odds ratio, 2.91[95% CI, 1.32- 6.99]). The main reason of readmission within 30 days after discharge was wound bleeding or infection. While intestinal obstruction was the major cause for readmission after 3 months of discharge. Conclusions: One-year unplanned readmission occurs frequently after CRC in Western China and is strongly associated with preoperative comorbidity. Attention should be paid to wound healing at the early stage of discharge, and bowel obstruction 3 months after discharge.

A video demonstration of the Li's anastomosis-the key part of the "non-tube no fasting" fast track program for resectable esophageal carcinoma

The main obstacle of fast track surgery for esophagectomy is early oral feeding. The main concern of early oral feeding is the possibility of increasing the incidence of anastomotic leakage. Dr. Yin Li used the Li's anastomosis to ensure oral feeding at will the first day after esophagectomy. This safe and efficient anastomosis method significantly reduced the anastomotic leak rate, the number of post-operative days and stricture. Importantly, the "non-tube no fasting" fast track program for esophageal cancer patients was conducted smoothly with Li's anastomosis. This article was focused on the surgical procedure of Li's anastomosis.

A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy

INTRODUCTION

This meta-analysis evaluated the safety and efficacy of fast track surgery (FTS) for patients with gastric cancer undergoing gastrectomy.

METHODS

Randomised controlled trials (RCTs) published between 1 January 1995 and 21 June 2013 comparing FTS with conventional perioperative care for patients with gastric cancer undergoing gastrectomy were identified in the PubMed, Embase™ and Cochrane Library databases, and were analysed systematically using RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark).

RESULTS

Seven RCTs (524 patients) were analysed. Compared with conventional perioperative care, FTS treatment with/without laparoscopy was associated with shorter postoperative hospitalisation, less hospitalisation expenditure (both p<0.00001), less pain and better quality of life. Short-term morbidity and readmission rates did not differ between treatments. No incidents of death occurred during the short-term follow-up period.

CONCLUSIONS

In patients with gastric cancer undergoing gastrectomy, the FTS pathway reduces the length and cost of postoperative hospitalisation while maintaining short-term morbidity, readmission and mortality rates comparable with those of conventional care.

Evolution of the Southampton Enhanced Recovery Programme for radical cystectomy and the aggregation of marginal gains

OBJECTIVE

To describe and assess the evolution of an enhanced recovery programme (ERP) for open radical cystectomy.

PATIENTS AND METHODS

We introduced a mentored ERP for radical cystectomy in January 2011. The programme underwent service evaluation and multiple changes in August 2012 that we define as marginal gains. We present a retrospective review of 133 consecutive patients undergoing open radical cystectomy, grouped according to the three stages of the ERP from October 2008 to April 2013: (1) non-ERP group (October 2008 to December 2010): n = 69; (2) ERP-1 group (January 2011 to July 2012): n = 37; and (3) ERP-2 group (August 2012 to April 2013): n = 27. Primary outcomes were length of hospital stay (LOS), readmission, morbidity at 90 days using the Clavien classification system and mortality. Secondary outcomes were time to flatus, ileus rates, re-operation rates and oncological outcomes.

RESULTS

There were no differences in patient demographics among any of the groups for: age, gender, BMI, American Society of Anesthesiologists score and the use of neoadjuvant chemotherapy. There were no differences in readmission, morbidity and mortality rates. The overall 90-day mortality was six patients (4.5%). There were significant differences in ileus rates between the non-ERP, the ERP-1 and the ERP-2 groups: 44.9% (31 patients), 29.7% (11 patients) and 14.8% (four patients), respectively (P = 0.017). There was a significant difference in the presence of pathological lymphadenopathy in the ERP-2 group: non-ERP group, 10.1%; ERP-1 group, 16.2%; and ERP-2 group, 44.4%; P = 0.002. There was also a difference in the mean (sd) lymph node yield in ERP-2: non-ERP group, 8.4 (5.4) nodes; ERP-1, 8.2 (6.4) nodes; and ERP-2, 16.7 (5.4) nodes (P < 0.001). The median (range) LOS was 14 (7-91) days, 10 (6-55) days and 7 (3-99) days in the non-ERP, ERP-1 and ERP-2 groups, respectively (P < 0.001).

CONCLUSIONS

Auditing an already successful ERP and implementing a number of marginal gains has led to a significant decrease in the median LOS for radical cystectomy. The LOS for open radical cystectomy at University Hospital Southampton has halved. In the second phase of our ERP, our median LOS is 7 days.

Early rehabilitation after surgery program versus conventional care during perioperative period in patients undergoing laparoscopic assisted total gastrectomy

OBJECTIVE

To evaluate the safety and efficacy of early rehabilitation after surgery program (ERAS) in patients undergoing laparoscopic assisted total gastrectomy.

MATERIALS AND METHODS

This is a study where 47 patients who are undergoing lap assisted total gastrectomy are selected. Twenty-two (n = 22) patients received enhanced recovery programme (ERAS) management and rest twenty-five (n = 25) conventional management during the perioperative period. The length of postoperative hospital stay, time to passage of first flatus, intraoperative and postoperative complications, readmission rate and 30 day mortality is compared. Serum levels of C-reactive protein pre-operatively and also on post-op day 1 and 3 are compared.

RESULTS

Postoperative hospital stay is shorter in ERAS group (78 ± 26 h) when compared to conventional group (140 ± 28 h). ERAS group passed flatus earlier than conventional group (37 ± 9 h vs. 74 ± 16 h). There is no significant difference in complications between the two groups. Serum levels of CRP are significantly low in ERAS group in comparison to conventional group. [d1 (52.40 ± 10.43) g/L vs. (73.07 ± 19.32) g/L, d3 (126.10 ± 18.62) g/L vs. (160.72 ± 26.18) g/L)].

CONCLUSION

ERAS in lap-assisted total gastrectomy is safe, feasible and efficient and it can ameliorate post-operative stress and accelerate postoperative rehabilitation in patients with gastric cancer. Short term follow up results are encouraging but we need long term studies to know its long term benefits.

Fast track program for esophagectomy patients

BACKGROUND

  A fast track (FT) program for esophagectomy patients is rarely used. We streamlined care using an algorithm for the postoperative care of patients who underwent esophagectomy to try to reduce hospital stays to 7 days while maintaining safety and patient satisfaction.

METHODS

  A consecutive series of 80 patients with esophageal carcinoma who underwent elective esophageal resection from 2007 to 2008 in our department was taken into the FT program. An algorithm for FT to guide postoperative care was used, featuring avoidance of the intensive care unit, early ambulation, removal of nasogastric tube and oral nutrition starting on postoperative day (POD) 1, with discharge on POD 7.

RESULTS

  All patients were operated upon through a left posterolateral thoracotomy with a cervical esophagogastrostomy. Seventy-eight (97.5%) patients completed the FT program. Discharge home was proposed for POD7. None was readmitted within 30 days of discharge. None suffered from anastomotic leakage. The time to first passage of flatus was 51.7 ± 8.4 h.

CONCLUSION

  The majority of patients with esophageal carcinoma can tolerate FT surgery. Oral nutrition starting on POD1 is safe and FT surgery is feasible for patients scheduled for elective esophageal cancer resections without compromising quality.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.