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Dasari BV, Thabut D, Allaire M, Berzigotti A, Blasi A, Line PD, Mandorfer M, Mazzafero V, Hernandez-Gea V. EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease. J Hepatol 2025:S0168-8278(25)00235-1. [PMID: 40348682 DOI: 10.1016/j.jhep.2025.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2025] [Accepted: 04/10/2025] [Indexed: 05/14/2025]
Abstract
Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.
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Pradhan A, Sarkar A, Haldar S, Chakraborty A, Pal AR. Compliance to enhanced recovery program in liver resection surgery: A retrospective cohort study. J Anaesthesiol Clin Pharmacol 2025; 41:318-322. [PMID: 40248802 PMCID: PMC12002699 DOI: 10.4103/joacp.joacp_5_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 04/19/2025] Open
Abstract
Background and Aims Liver resection is a complex surgery, and optimizing recovery is critical to ensure that patients can promptly regain their health and quality of life. The authors present a retrospective cohort study on Enhanced Recovery After Surgery (ERAS) in liver resection aimed at correlating compliance with ERAS elements to length of stay (LOS) and the incidence of complications in a tertiary-level cancer hospital in Eastern India. Material and Methods In total, 44 hepatectomy patients were assessed retrospectively from June 2022 to May 2023. Data were collected from electronic medical records and patient charts. Results The overall compliance was 77.7%. Individual component compliance varied. Lower compliance rates were seen with some aspects such as fasting and carbohydrate loading, minimally invasive surgical techniques used, and avoidance or early removal of the drain. The cohort was divided into two groups. Group 1 had compliance to ≥75% of 21 elements of ERAS, and group 2 had compliance to <75%. Statistical analysis showed higher ERAS compliance and reduced complications, although LOS differences were not statistically significant (group 1 and group 2 with an LOS difference of 1 day). Severe complications such as re-exploration and death were noted in the group of patients with compliance to less than 75% of the components. Conclusion With increased ERAS compliance, the patients benefited clinically and financially.
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Affiliation(s)
- Abiya Pradhan
- Department of Onco-Anaesthesia, Tata Medical Center, Kolkata, West Bengal, India
| | - Anshuman Sarkar
- Department of Onco-Anaesthesia, Tata Medical Center, Kolkata, West Bengal, India
| | - Srimanta Haldar
- Department of Onco-Anaesthesia, Tata Medical Center, Kolkata, West Bengal, India
| | | | - Angshuman Rudra Pal
- Department of Onco-Anaesthesia, Tata Medical Center, Kolkata, West Bengal, India
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Akbuğa GA, Yılmaz K. Obstacles to Compliance and Implementation of ERAS Protocol From Nursing Perspective: A Qualitative Study. J Perianesth Nurs 2025; 40:331-336. [PMID: 39243250 DOI: 10.1016/j.jopan.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 05/06/2024] [Accepted: 05/17/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE Enhanced Recovery After Surgery (ERAS) is a concept that covers evidence-based practices and requires multidisciplinary teamwork, and nurses play a key role in this team. This qualitative research is conducted to describe the experiences of nurses implementing ERAS and the obstacles they encounter in practice. DESIGN This research was conducted using the phenomenology pattern, one of the qualitative research designs. METHODS The research study group was determined by criterion sampling, one of the purposeful sampling methods.The criterion for participation in this study is to follow at least one of the steps of the ERAS protocol and volunteer to participate in the study. In this context, 12 nurses who met the inclusion criteria participated in the study. Data were obtained from May 1 to May 31, 2023 using an introductory information form and a semistructured interview form. The introductory information form asked questions such as age, gender, marital status, working year, ERAS application time, and total working year. The semistructured interview form, developed by the authors based on the related literature, consisted of four open-ended questions 1The obtained data were analyzed using the seven-step Colaizzi method. FINDINGS The study identified three themes: the importance of the ERAS protocol, the obstacles to the ERAS protocol, compliance with the ERAS protocol and applicability. Nine subthemes were found: reducing complications and accelerating the healing process, increasing the level of satisfaction, lack of knowledge, leader confusion, resistance to change, lack of team cooperation, policy, leadership, and education. CONCLUSIONS This study revealed the experiences of nurses who implement at least one component of ERAS protocols regarding the obstacles to the implementation of the protocol. As a result, nurses stated that lack of information and team cooperation, leader complexity, and resistance to change were obstacles to the protocol. Identifying the obstacles encountered in the implementation of the protocols is important for producing solution suggestions.
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Affiliation(s)
- Gökçen Aydın Akbuğa
- Faculty of Health Sciences, Department of Nursing, Yozgat Bozok University, Yozgat, Türkiye
| | - Kübra Yılmaz
- Faculty of Health Sciences, Department of Nursing, Ankara Yıldırım Beyazıt University, Ankara, Türkiye.
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Ciulli C, Fogliati A, Scacchi A, Scotti MA, Aprigliano M, Braga M, Romano F, Garancini M. Early compliance to enhanced recovery protocol as a predictor of complications after liver surgery. Updates Surg 2025:10.1007/s13304-025-02148-7. [PMID: 40087243 DOI: 10.1007/s13304-025-02148-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 02/26/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND Enhanced Recovery Protocol (ERP) has the purpose of minimising postoperative hospitalisation and expediting the restoration of preoperative patient conditions. This study seeks to investigate the correlation between early non-compliance to postoperative items within ERP and complications in liver surgery. METHODS From January 2019 to December 2022 the ERP was proposed to all consecutive patients undergoing liver surgery. Nasogastric tube removal, resuming oral intake and mobilisation and obtaining an adequate glycaemic control were the postoperative items considered as non-compliance indicators. Data were prospectively collected and analysed. RESULTS 192 patients were included, comprising 99(51.6%) hepatocellular carcinoma, 58(30.2%) colorectal metastasis and 24(12.5%) benign/other pathology. A minimally invasive approach was adopted in 57.3% of cases. Postoperative morbidities occurred in 44.8% of patients, while major complications in 13% of patients. Cirrhosis (p < 0.001), minimally invasive approach (p < 0.004), early oral intake (p < 0.019) and early mobilisation (p < 0.019) significantly correlated to morbidity at multivariate analysis. The complication rate escalated from 26.9% in fully compliant patients, to 58% in patients with two non-compliance indicators and to 91.2% in fully non-compliant patients (p < 0.001). The same trend was confirmed for major complications (p < 0.001). CONCLUSIONS Early non-compliance to ERP postoperative items in liver surgery was significantly associated with overall and major morbidity.
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Affiliation(s)
- Cristina Ciulli
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy.
| | - Alessandro Fogliati
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Andrea Scacchi
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Mauro Alessandro Scotti
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
| | - Michele Aprigliano
- Department of Anesthesiology and Intensive Care Medicine, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Fabrizio Romano
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Mattia Garancini
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
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Jin O, Xu T, Lai J, He J, Wu Y, Yang X. Impact of enhanced recovery after surgery concept process optimization on the perioperative period of gynecologic laparoscopic surgery. BMC Womens Health 2025; 25:120. [PMID: 40087739 PMCID: PMC11907852 DOI: 10.1186/s12905-025-03626-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Accepted: 02/21/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND To explore the impact of enhanced recovery after surgery (ERAS) optimization concept process on the perioperative period of gynecologic laparoscopic surgery. METHODS This retrospective observational study included patients who underwent gynecologic laparoscopic surgery based on ERAS concept process optimization (ERAS group) for uterine fibroids, adenomyosis, and ovarian cysts at Jiaxing Hospital of Traditional Chinese Medicine between January 2023 and December 2023. Patients who underwent the same laparoscopic protocol without ERAS concept process optimization between January 2022 and December 2022 were matched as the control group (non-ERAS group). Postoperative indexes and patient satisfaction were compared between the two groups. RESULTS A total of 120 patients were included, with 60 of who underwent gynecologic laparoscopic surgery (total laparoscopic hysterectomy, TLH: n = 20; laparoscopic myomectomy, LM: n = 20; laparoscopic ovarian cystectomy, LOC: n = 20) based on ERAS (ERAS group), and the other 60 of who underwent gynecologic laparoscopic surgery (TLH: n = 20, LM: n = 20, LOC: n = 20) without ERAS (non-ERAS). In patients received gynecologic laparoscopic surgery of ERAS group, the time of first postoperative gas evacuation, the time of semi-liquid recovery, the time of urination, the time of incision pain, and the length of hospital stay were significantly shorter (all P < 0.001), and the number of nausea and vomiting was significantly reduced (all P < 0.001) compared with those in the non-ERAS group. Besides, satisfaction of patients receiving ERAS was significantly higher than in the non-ERAS group (TLH: P < 0.01; LM and LOC: P < 0.001). CONCLUSIONS ERAS optimization for gynecologic laparoscopic surgery improved patients' outcomes, reduced complications, and improved patient's satisfaction.
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Affiliation(s)
- Ou Jin
- Department of Gynecology, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang University of Traditional Chinese Medicine, Jiaxing, Zhejiang, 314000, China
| | - Tiebing Xu
- Shenyang Sujiatun District Women's and Children's Hospital, Shenyang, 110101, China
| | - Juan Lai
- Department of Gynecology, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang University of Traditional Chinese Medicine, Jiaxing, Zhejiang, 314000, China
| | - Junxia He
- Department of Gynecology, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang University of Traditional Chinese Medicine, Jiaxing, Zhejiang, 314000, China
| | - Yongfeng Wu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, 310006, China
- Department of Gynecology, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, 310006, China
| | - Xiaomin Yang
- Department of Gynecology, Jiaxing Hospital of Traditional Chinese Medicine, Zhejiang University of Traditional Chinese Medicine, Jiaxing, Zhejiang, 314000, China.
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Choudhary SK, Bijarniya D, Jat SK, Agrawal M, Vasudeva S. Effect of the enhanced recovery after surgery protocol in patients undergoing elective craniotomies: a systematic review and meta-analysis. Neurosurg Rev 2025; 48:291. [PMID: 40063290 DOI: 10.1007/s10143-025-03446-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2024] [Revised: 02/23/2025] [Accepted: 03/03/2025] [Indexed: 05/13/2025]
Abstract
Enhanced recovery after surgery protocol (ERASP) improves postoperative outcomes. However, its implementation in neurosurgery remains under explored, resulting in the absence of standard evidence-based guidelines. Thus, we compared the outcomes of ERASP and conventional perioperative care (CPC) in patients undergoing elective craniotomy for various intracranial pathologies. This systematic review and meta-analysis involved the search of PubMed, Cochrane Library, and Google Scholar until December 4, 2024. The primary outcomes were total and postoperative length of stay (LOS). Secondary outcomes included hospitalization cost, pain, analgesic use, Karnofsky performance status (KPS) score, postoperative nausea and vomiting (PONV), postoperative complications, 30-days readmission and reoperation, and mortality. A total of 15 studies, including randomized controlled trials (n = 9) as well as prospective and retrospective studies (each n = 3) were included. Compared to CPC, ERASP significantly reduced total LOS (MD -3.32, 95%CI -3.66 to -2.98; P < 0.0001, I2 = 34%), postoperative LOS (MD -2.80, 95%CI -3.82 to -1.79; P < 0.0001, I2 = 90%), hospitalization cost (MD -$1044, 95%CI -$1289 to -$800; P < 0.0001, I2 = 47%), postoperative pain (MD -1.55, 95%CI -1.92 to -1.19; P < 0.0001, I2 = 83%), analgesic use (OR 0.56, 95%CI 0.40 to 0.80; P = 0.001, I2 = 0%), KPS score (MD 6.68, 95%CI 0.15 to 13.21; P = 0.045, I2 = 93%), respiratory complications (OR 0.28, 95%CI 0.13 to 0.58; P = 0.001, I2 = 0%), and PONV (OR 0.39, 95%CI 0.27 to 0.57; P < 0.0001, I2 = 0%). While ERASP and CPC were comparable regarding other outcome measures. Thus, in elective craniotomy, ERASP shortens total and postoperative LOS, decreases hospitalization costs, improves functional recovery, decreases pain and analgesic use, with reduced incidence of PONV and respiratory complications.
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Affiliation(s)
- Suresh Kumar Choudhary
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, 302004, India
| | - Dinesh Bijarniya
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, 302004, India
| | - Shravan Kumar Jat
- Department of Anesthesia, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, 302004, India
| | - Manish Agrawal
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, 302004, India
| | - Shubham Vasudeva
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, 302004, India.
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Ljungqvist O. Managing surgical stress: Principles of enhanced recovery and effect on outcomes. Clin Nutr ESPEN 2025; 67:56-61. [PMID: 40058494 DOI: 10.1016/j.clnesp.2025.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Accepted: 02/20/2025] [Indexed: 03/14/2025]
Affiliation(s)
- Olle Ljungqvist
- Karolinska Institutet & Örebro University, Sweden; School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden; Department of Surgery, Örebro University Hospital, SE-701 85 Örebro, Sweden.
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Ellwanger MP, Ellwanger MP, Jardine MB, Bramucci V, Hammes SAP, Lopes LM, Munhoz ACM. Effectiveness of Enhanced Recovery After Surgery protocol in pancreatic surgery: a systematic review and meta-analysis of randomized controlled trials. J Gastrointest Surg 2025; 29:101939. [PMID: 39755202 DOI: 10.1016/j.gassur.2024.101939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 11/29/2024] [Accepted: 12/27/2024] [Indexed: 01/06/2025]
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol represents an advancement in perioperative care to reduce surgical stress and accelerate recovery. This meta-analysis aimed to evaluate the effectiveness of ERAS in pancreatic surgery and to assess the effect of the ERAS protocol vs conventional hospital care on postoperative outcomes, including length of stay (LOS) in the hospital, hospital costs, readmission rates, and infection rates in patients undergoing pancreatic surgery. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane Central Register of Controlled Trials, and Embase were searched to identify relevant RCTs. Data were extracted and analyzed using a random effects model. Statistical analyses were performed using RStudio. RESULTS A total of 7 RCTs involving 731 patients were included. The meta-analysis showed a statistically significant reduction in LOS by 2.49 days (mean difference, -2.49; 95% CI, -4.20 to -0.79; P <.01) with considerable heterogeneity (I2 = 86%). Hospital costs were significantly reduced (standardized mean difference, -0.36; 95% CI, -0.65 to -0.06; P =.02) with moderate heterogeneity (I2 = 52%). The readmission and infection rates showed no statistically significant differences between the ERAS and control groups. The Egger test indicated no significant publication bias. CONCLUSION The ERAS protocol significantly reduced LOS and hospital costs in patients who underwent pancreatic surgery. Our findings support the implementation of ERAS protocols to enhance recovery and optimize outcomes. To the best of our knowledge, our study is the first to demonstrate these results using an RCT-only meta-analysis approach in pancreatic surgery, highlighting the value of ERAS in improving perioperative care.
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Affiliation(s)
| | | | | | - Victoria Bramucci
- Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Lucca Moreira Lopes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Yu ZQ, Huang DK, Guo S, Wang K. A Retrospective Study of the Implementation of Enhanced Recovery After Unicompartmental Knee Arthroplasty. Orthopedics 2025; 48:87-97. [PMID: 40085153 DOI: 10.3928/01477447-20250305-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2025]
Abstract
BACKGROUND The goal of this study is to report our findings on the application of the enhanced recovery after surgery (ERAS) protocol for patients undergoing unicompartmental knee arthroplasty (UKA) and to evaluate the benefits and drawbacks of this approach. MATERIALS AND METHODS Sixty patients with medial unicompartmental knee osteoarthritis (UKOA) who underwent UKA were the subject of a retrospective investigation. The patients were categorized into 2 groups based on the use of ERAS protocols. Among the metrics that were measured and statistically analyzed were Kellgren-Lawrence grade, femorotibial angle (FTA), Tegner activity score, Lysholm knee score, University of California at Los Angeles (UCLA) activity score, Berg Balance Scale (BBS), numeric pain rating scale (NPRS) score, forgotten joint score, range of motion (ROM), hospital length of stay (LOS), procedure duration, intraoperative bleeding volume, time to ambulation, time to resume normal walking, duration of urinary catheter retention, time to resume a regular diet, and postoperative satisfaction. RESULTS The patients allocated to the ERAS cohort showed distinct characteristics compared with the control cohort, including faster resumption of regular dietary intake, ambulation, and gait patterns. The ERAS group showed a decreased FTA and improved BBS scores. On final evaluation, the ERAS group had lower UCLA scores, indicative of superior overall outcomes. CONCLUSION The initial application of ERAS showed promising results in enhancing patient rehabilitation outcomes, reducing the impact of hospitalization, and improving efficient allocation of health care resources. Nevertheless, additional research is necessary to assess the feasibility and effectiveness of widespread implementation for patients undergoing UKA. [Orthopedics. 2025;48(2):87-97.].
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Mohamed Y, Hussein A, Elsaba O, Rhodes M, Alloush K, Elhofy E, Shokry A. Optimizing Postoperative Outcomes in Abdominal Surgery: The Role of Enhanced Recovery After Surgery (ERAS) Protocols. Cureus 2025; 17:e79258. [PMID: 40125160 PMCID: PMC11926401 DOI: 10.7759/cureus.79258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2025] [Indexed: 03/25/2025] Open
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) protocols aim to reduce surgical stress, enhance recovery, and minimize the length of hospital stays, thereby improving both clinical outcomes and the overall patient experience. The main objective of the study was to find the postoperative outcomes of abdominal surgery with respect to the role of ERAS protocols. METHODOLOGY Data was collected retrospectively from three governmental hospitals in Egypt between 2018 and 2020. A total of 1473 patients were enrolled according to the criteria of the study, 780 in the ERAS group and 693 in the non-ERAS group. RESULTS The mean age of patients in both groups was similar, with 55.4 (±10.2) years for the ERAS group and 54.8 (±9.8) years for the non-ERAS group. The gender distribution showed a slightly higher number of female patients in both groups. The average BMI was comparable between groups, with 26.3±4.5 kg/m² in the ERAS group and 26.5±4.7 kg/m² in the non-ERAS group. The time to first flatus was reduced from 52.3 (±10.4) hours in the non-ERAS group to 36.2±8.1 hours in the ERAS group (P < 0.001). Similarly, the time to first defecation was shorter in the ERAS group at 48.5±9.2 hours compared to 66.4±12.5 hours in the non-ERAS group (P < 0.001). CONCLUSION ERAS protocols significantly improve postoperative outcomes in abdominal surgeries by reducing recovery times, complications, and hospital stays.
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Affiliation(s)
- Younis Mohamed
- General Surgery, Betsi Cadwaladr University Health Board, Bangor, GBR
| | - Ahmed Hussein
- Orthopedic Surgery, Alexandria University Hospitals, Alexandria, EGY
| | | | - Mahmoud Rhodes
- Trauma and Orthopaedics, Nasser Institute Hospital for Research and Treatment, Cairo, EGY
| | - Khalid Alloush
- Obstetric and Gynecology, Alexandria University Hospitals, Alexandria, EGY
| | - Eman Elhofy
- General Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Ahmed Shokry
- Trauma and Orthopedic, Aneurin Bevan University Health Board, Newport, GBR
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Pei J, Wang S, Pan X, Wu M, Zhan X, Fang K, Wang D, Wang W, Zhu G, Tang H, An N, Peng J. Effect of enhanced recovery after surgery on postoperative outcomes in children undergoing robot-assisted laparoscopic pyeloplasty. J Pediatr Urol 2025; 21:181-190. [PMID: 39389872 DOI: 10.1016/j.jpurol.2024.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 09/18/2024] [Accepted: 09/23/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE To assess the effects of the enhanced recovery after surgery (ERAS) perioperative protocol on the outcomes of robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients. METHODS A total of 57 children who underwent RALP at our center between November 2021 and December 2023 were included in the study. They were randomly assigned to either the ERAS (intervention) group or the non-ERAS (control) group. The analysis focused on comparing the length of hospital stay, recovery of gastrointestinal function, incidence of complications within 90 days post-surgery, postoperative extubation time (urinary tube and double-J tube), postoperative auxiliary examinations, and readmission rates within 30 days. Additionally, the patients were divided into two age groups: <4 years old and ≥4 years old, to assess pain severity. RESULTS There were no significant differences in preoperative general information, preoperative auxiliary examination findings, or intraoperative conditions between the ERAS and non-ERAS groups. The ERAS group had a significantly shorter postoperative hospital stay compared to the non-ERAS group. Furthermore, the time to the first postoperative bowel movement was shorter, and the incidence of postoperative complications was significantly lower in the ERAS group. Among children <4 years old, there was no significant difference in pain severity between the two groups. However, in children ≥4 years old, the ERAS group experienced significantly lower pain levels at 6 and 24 h post-surgery compared to the non-ERAS group. DISCUSSION The findings of this prospective randomized controlled trial should determine if ERAS is superior to traditional perioperative management in children undergoing RALP, particularly regarding postoperative hospital stay, intestinal function recovery, pain response, and complication rates. We anticipate that our data will offer valuable clinical insights and guidance for the implementation of ERAS in pediatric robotic surgery for urinary diseases. CONCLUSION The ERAS protocol can reduce the length of hospital stay, aid in the recovery of gastrointestinal function, and lower postoperative complication rates. It also has the potential to lessen postoperative pain to varying degrees in certain pediatric patients. ERAS is a safe and effective protocol for pediatric patients undergoing RALP.
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Affiliation(s)
- Jun Pei
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Shili Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Xingyu Pan
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Moudong Wu
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Xiong Zhan
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Dan Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Wei Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Guohua Zhu
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Hongyu Tang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Nini An
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
| | - Jinpu Peng
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
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Moral V, Jericó C, Abad Motos A, Páramo JA, Quintana Díaz M, García Erce JA. 2024 critical review of the patient blood management (PBM) recommendations of the Spanish enhanced recovery after major surgery (via RICA). Cir Esp 2025; 103:104-114. [PMID: 39617300 DOI: 10.1016/j.cireng.2024.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 10/22/2024] [Indexed: 12/12/2024]
Abstract
The Spanish enhanced recovery in adult surgery strategy, the "RICA pathway", was published in 2021 and includes 19 specific recommendations and more than 20 indirect recommendations for patient blood management (PBM). After reviewing these recommendations, and in the context of the new clinical evidence available, we propose the following updates: First: Detection and treatment of any preoperative anemia status in ALL patients who are candidates for major surgery with hematinic deficiencies. Second: Universal use of tranexamic acid in major surgery, bedside monitoring of intraoperative hemoglobin levels, restrictive transfusion criteria, and monitoring of patient well-being in terms of hydration, coagulability, normothermia and analgesia. Third: Restrictive transfusion criteria, single-unit blood transfusion and diagnosis/treatment of postoperative anemia. Real, universal implementation and integration of PBM in the RICA program is urgently needed.
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Affiliation(s)
- Vicky Moral
- Servicio de Anestesia, Hospital Universitario Sant Pau and Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Carlos Jericó
- Servicio de Medicina Interna, Complex Hospitalari Moisès Broggi, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain; Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico (Anemia Working Group España), Madrid, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Madrid, Spain; Grupo de Investigación Gestión en el Paciente Sangrante-PBM, Instituto de Investigación Sanitaria, Hospital Universitaria La Paz (IdiPAZ), Madrid, Spain
| | - Ane Abad Motos
- Departamento de Anestesiología, Hospital Universitario Donostia, San Sebastián, Spain; Spanish Perioperative Audit and Research Network (ReDGERM), Zaragoza, Spain; Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain
| | - José Antonio Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona, Spain; Laboratory of Atherothrombosis, Cima Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, Spain; CIBERCV, ISCIII, Madrid, Spain
| | - Manuel Quintana Díaz
- Grupo Español de Rehabilitación Multimodal (GERM), Madrid, Spain; Sección Servicio Medicina Intensiva, Escuela de Simulación, CEASEC, Spain; Dpto Medicina, UAM, Hospital Universitario La Paz | IdiPAZ, Spain; Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), Spain
| | - José Antonio García Erce
- Servicio de Medicina Interna, Complex Hospitalari Moisès Broggi, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain; Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico (Anemia Working Group España), Madrid, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Madrid, Spain; Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain.
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Oehring R, Keshi E, Hillebrandt KH, Koch PF, Felsenstein M, Moosburner S, Schöning W, Raschzok N, Pratschke J, Neudecker J, Krenzien F. Enhanced recovery after surgery society's recommendations for liver surgery reduces non surgical complications. Sci Rep 2025; 15:3693. [PMID: 39880966 PMCID: PMC11779921 DOI: 10.1038/s41598-025-86808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 01/14/2025] [Indexed: 01/31/2025] Open
Abstract
Enhanced Recovery after Surgery (ERAS) is a multimodal approach to improve surgical outcome and has been implemented in many fields of surgery in an international scale. The aim of this study was to evaluate the effect of the Enhanced Recovery after Surgery (ERAS) society recommendations in liver surgery and the impact on general and surgery-related complications. 1049 patients who underwent liver surgery from July 2018 to October 2023 were included. The ERAS program strictly followed the official ERAS society recommendations. As a control group (Non-ERAS) 90 patients were treated according to the clinic standard, while 959 patients were treated according within the ERAS measures. After propensity score (PSM) matching 87 Non-ERAS and 258 ERAS patients were analyzed by complications and cumulative sum analysis (CUSUM). ERAS implementation resulted in a significant decrease in general complications (control 27.6% vs. ERAS 16.3%, p = 0.033), largely attributed to a reduction in infection-related complications (control 20.7% vs. ERAS 9.7%, p = 0.007). When examining surgery-related complications no significant disparities were observed (control 17.2% vs. ERAS 17.1%, p = 0.968). The CUSUM analysis of general and non-surgical complications showed that the full effect of the ERAS program only became apparent after several years. Moreover, adherence increased over time consecutively from 62.5 to 72.5% in 4 years. The ERAS society recommendations for liver surgery reduced general complications but did not have any effect on surgery related complications. The effect of the ERAS program progressively improved over the years, highlighting the need for continuous effort to maintain and further enhance outcomes.
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Affiliation(s)
- Robert Oehring
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Department of Surgery, Harzklinikum D.C. Erxleben, Quedlinburg, Germany
| | - Eriselda Keshi
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Karl-Herbert Hillebrandt
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Pia F Koch
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Simon Moosburner
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 13353, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
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Shi J, Chen S, Nie J, Xiong K, Wang G, Qian K, Zheng H, Wang X. Enhanced recovery after surgery protocol optimizes results and cost of laparoscopic radical nephroureterectomy. BMC Surg 2025; 25:14. [PMID: 39780183 PMCID: PMC11715194 DOI: 10.1186/s12893-025-02758-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 01/02/2025] [Indexed: 01/11/2025] Open
Abstract
PURPOSE To evaluate the efficacy of an enhanced recovery after surgery (ERAS) strategy for upper tract urothelial carcinoma (UTUC) patients undergoing laparoscopic radical nephroureterectomy (LRNU). METHODS 90 patients who received LRNU at Zhongnan Hospital of Wuhan University between January 2018 and July 2022 were retrospectively analyzed, including 43 in the ERAS group and 47 in the pre-ERAS group. The clinical features, postoperative complications, length of hospital stay (LOS), and hospital expenditures of the two groups were compared via t-test, Mann-Whitney test, and Chi-square test. RESULTS In comparison to the pre-ERAS group, the total and postoperative LOS were significantly shorter in the ERAS group [total LOS: 15.0 (13.0-20.0) vs. 21.0 (16.0-26.0), p < 0.001; postoperative LOS: 8.0 (7.0-9.0) vs. 11.0 (9.0-13.0), p < 0.001]. The ERAS group had lower hospitalization costs than that in the pre-ERAS group [56896.40 (48324.30-67498.01) vs. 64249.83 (55574.36-81581.82), p = 0.010]. Additionally, the ERAS group experienced a reduction in postoperative fever incidence (23.4% vs. 4.7%, p = 0.011). CONCLUSIONS In the realm of LRNU, ERAS protocols are safe and practical for minimizing the LOS while accelerating the rehabilitation of patients undergoing LRNU. This study offers insights for enhancing ERAS protocols for UTUC patients even further.
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Affiliation(s)
- Jiageng Shi
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Siming Chen
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiawei Nie
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kangping Xiong
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Gang Wang
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Human Genetics Resource Preservation Center of Hubei Province, Wuhan, China
| | - Kaiyu Qian
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Human Genetics Resource Preservation Center of Hubei Province, Wuhan, China
| | - Hang Zheng
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China.
| | - Xinghuan Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China.
- Medical Research Institute, Wuhan University, Wuhan, China.
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Pai SL, Ladlie B, Locke K, Garcia Getting R. Patient-Centered Care for Ambulatory Surgery. Int Anesthesiol Clin 2025; 63:14-22. [PMID: 39651664 DOI: 10.1097/aia.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2024]
Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Beth Ladlie
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Keya Locke
- Department of Anesthesiology and Perioperative Medicine, University of Florida, Jacksonville, Florida
| | - Rosemarie Garcia Getting
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Amjad T, Malana MA, Khan MSN, Hasan SA, Fahad S, Haider M. Optimizing Surgical Outcomes: The Role of Enhanced Recovery After Surgery (ERAS) Protocols in Improving Recovery and Reducing Hospital Stays in Pakistan. Cureus 2025; 17:e76713. [PMID: 39897315 PMCID: PMC11783200 DOI: 10.7759/cureus.76713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2024] [Indexed: 02/04/2025] Open
Abstract
Background Enhanced recovery after surgery (ERAS) procedures are increasingly recognized for their ability to improve surgical outcomes and shorten hospital stays, particularly in resource-constrained environments like Pakistan. This study underscores the transformative potential of ERAS protocols in not only enhancing patient recovery but also optimizing healthcare resource utilization in such settings. The research aimed to evaluate the effectiveness of ERAS protocols in reducing postoperative complications and hospital stays among surgical patients in Pakistan, with a focus on their impact on overall recovery and healthcare efficiency. Methodology A prospective cohort design was employed, recruiting 400 adult patients aged 18 years and older undergoing elective surgical procedures from January to December 2023. Data on demographics, adherence to ERAS procedures, postoperative complications, duration of hospital stay, and recovery metrics were gathered before, during, and after surgery for participants who were split into ERAS and standard care groups. To compare results between groups, statistical procedures such as t-tests and chi-square tests were used. Results The ERAS group exhibited a significantly shorter mean length of hospital stay (3.52 ± 1.27 days) compared to the standard care group (6.29 ± 2.15 days, p < 0.001). Full recovery rates at 30 days, three months, and six months were significantly higher in the ERAS group, with 160 patients (80.0%), 178 patients (89.0%), and 191 patients (95.5%), respectively. In contrast, the standard care group showed recovery rates of 122 patients (61.0%), 147 patients (73.5%), and 164 patients (82.0%) at the same intervals. The ERAS group also had lower rates of postoperative complications, with 176 patients (88.0%) experiencing no complications compared to 152 patients (76.0%) in the standard care group, and lower readmission rates, with nine patients (4.5%) compared to 19 patients (9.5%) in the standard care group. Conclusion The successful implementation of ERAS procedures in Pakistan highlights their potential to improve healthcare efficiency by increasing surgical recovery and lowering hospital stays.
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Affiliation(s)
- Talha Amjad
- Anatomy, Hazrat Bari Imam Sarkar (HBS) Medical and Dental College, Islamabad, PAK
| | - Muhammad Ali Malana
- General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, PAK
| | | | - Syed Asad Hasan
- Biochemistry, Hazrat Bari Imam Sarkar (HBS) Medical and Dental College, Islamabad, PAK
| | - Shah Fahad
- Biochemistry, Hazrat Bari Imam Sarkar (HBS) Medical and Dental College, Islamabad, PAK
| | - Maithem Haider
- Physiology, Hazrat Bari Imam Sarkar (HBS) Medical and Dental College, Islamabad, PAK
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Zhang L, Dai F, Zeng Q, He X, Guo N, Chen X, Li K. Factors retarding enhanced recovery from thermal ablation of liver tumors: A single-center prospective study. J Cancer Res Ther 2024; 20:2103-2109. [PMID: 39792421 DOI: 10.4103/jcrt.jcrt_1302_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 11/01/2024] [Indexed: 01/12/2025]
Abstract
PURPOSE To evaluate the risk factors that may delay enhanced recovery in the ablation of liver tumors. METHODS A total of 310 patients who underwent ultrasound-guided ablation of liver tumors under general anesthesia were prospectively enrolled. Baseline data, intraoperative parameters, and postoperative events were evaluated. Postoperative pain was scored using the visual analog scale (VAS). Logistic regression analysis was conducted for univariate and multivariate analyses. RESULTS The study included 42 females (13.5%) and 268 males (86.5%). The mean age of the sample was 57 ± 11 years old. The average length of stay (LOS) was 4.3 ± 2.4 days. A total of 199 out of 310 patients (64.2%) experienced moderate to severe pain (VAS score > 3). Seventy out of 310 patients (22.6%) experienced other complications. In the multivariable analysis, the number of lesions [odds ratio (95% confidence interval): 3.23 (2.15-4.84); P < 0.001], maximum diameter of lesions [1.12 (1.07-1.17), P < 0.001], and smallest distance between the lesions and the liver capsule [0.91 (0.89-0.94), P < 0.001] were risk factors for postoperative pain (VAS > 3). A history of alcohol consumption [2.62 (1.33-5.19), P = 0.005] was a risk factor for other complications. Surgical history [0.40 (0.24-0.67), P = 0.001] was a protective factor against LOS. Total operation time [1.01, 1.00-1.01, P = 0.009] was a mild risk factor for LOS. CONCLUSION The number of lesions, maximum diameter of the lesions, smallest distance between the lesions and the liver capsule, total operation time, and a history of alcohol use were risk factors that may delay enhanced recovery in patients undergoing ablation of liver tumors. These findings may provide evidence to promote the use of the enhanced recovery after surgery protocol.
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Affiliation(s)
- Lanxia Zhang
- Department of Ultrasound, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
| | - Fei Dai
- Ultrasound in Medicine, Second Affliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, China
| | - Qingjing Zeng
- Department of Ultrasound, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
| | - Xuqi He
- Department of Ultrasound, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
| | - Na Guo
- Department of Anesthesiology, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
| | - Xiaorui Chen
- Department of Anesthesiology, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
| | - Kai Li
- Department of Ultrasound, The Third Affliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China
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Shah AA, Alnajib AMA, Baldaniya L, Hassan H, Kaur P, Sharma R, Ramzan HS, Sami W. Investigating the Effectiveness of Enhanced Recovery after Surgery (ERAS) Protocols in Improving Postoperative Outcomes and Reducing Hospital Readmission Rates in Patients Undergoing abdominal Surgery. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2024; 16:S3534-S3537. [PMID: 39926912 PMCID: PMC11805166 DOI: 10.4103/jpbs.jpbs_1044_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 08/26/2024] [Accepted: 08/28/2024] [Indexed: 02/11/2025] Open
Abstract
Objectives The main objective of the study is to determine the effectiveness of enhanced recovery after surgery (ERAS) protocols in improving postoperative outcomes and reducing hospital readmission rates in patients undergoing abdominal surgery. Materials and Methods This study involves a total of 650 patients who were divided into two groups: the intervention group, which received care according to ERAS protocols, and the control group, which received standard postoperative care. Patients aged >18 years and scheduled for elective abdominal surgery were included in the study. Results The mean age of patients in ERAS group were 56.4 ± 12.3 years, while in the standard care group 57.1 ± 11.8 years. Out of 650 patients, there were 339 male and 311 female. Patients were selected from different surgery departments. The ERAS group had lower 30-day readmission rates (6.2% vs. 15.4%), quicker mobilization (12.5 vs. 24.8 hours), and faster resumption of oral intake (8.6 vs. 18.2 hours). Pain levels were lower (VAS 3.1 vs. 5.8), and patient satisfaction was higher (89% vs. 74%) in the ERAS group, with all differences being statistically significant. Conclusion It is concluded that ERAS protocols significantly improve postoperative outcomes, including reducing complications, shortening hospital stays, and lowering readmission rates for patients undergoing elective abdominal surgery.
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Affiliation(s)
- Ali Akbar Shah
- Department of General Surgery, London North West NHS Trust, United Kingdom
| | | | - Lalji Baldaniya
- Marwadi University Research Center, Department of Pharmacy, Faculty of Health Sciences, Marwadi University, Rajkot, Gujarat, India
| | - Halijah Hassan
- Management and Science University, Shah Alam, Selangor, Malaysia
| | - Parjinder Kaur
- Department of Pharmacy, Chandigarh Pharmacy College, Chandigarh Group of Colleges, Jhanjeri, Mohali, Punjab, India
| | - Rajesh Sharma
- Department of Pharmacology, NIMS Institute of Pharmacy, NIMS University, Jaipur, Rajasthan, India
| | - Hafiza Sobia Ramzan
- Department of Biochemistry, Institute of Molecular Biology and Biotechnology, University of Lahore, Pakistan
| | - Waqas Sami
- College of Nursing, QU-Health, Qatar University, Doha, Qatar
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Lv Q, Xiang YC, Qiu YY, Xiang Z. Safety and efficacy of the enhanced recovery after surgery protocol in hepatectomy for liver cancer. Clin Res Hepatol Gastroenterol 2024; 48:102493. [PMID: 39571193 DOI: 10.1016/j.clinre.2024.102493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 10/20/2024] [Accepted: 11/06/2024] [Indexed: 12/08/2024]
Abstract
PURPOSE The aim of this research was to evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) protocol in hepatectomy patients with liver cancer. MATERIALS AND METHODS We searched three databases, including PubMed, Embase, and the Cochrane Library database, from inception to April 25, 2023. The outcomes were postoperative complications, and postoperative length of stay (PLOS). This study was performed by Stata (V. 16.0) software. RESULTS Twelve investigations involving 1,892 patients were included in this study. The ERAS group had lower overall postoperative complications [odds ratio (OR) = 0.49, I² = 54.89 %, 95 % confidence interval (CI) = 0.33-0.74, P = 0.00], postoperative Clavien-Dindo Grade 1-2 complications (OR = 0.39, I² = 55.14 %, 95 %CI = 0.23-0.69, P = 0.00), Clavien-Dindo Grade 3-4 complications (OR = 0.56, I² = 0.00 %, 95 %CI = 0.38-0.83, P = 0.00) , pneumonia (OR = 0.34, I² = 0.00 %, 95 %CI = 0.15-0.76, P = 0.01), ascites (OR = 0.25, I² = 0.00 %, 95 %CI = 0.09-0.68, P = 0.01), vomit (OR = 0.39, I² = 0.00 %, 95 %CI = 0.21-0.73, P = 0.00), intraoperative blood loss [mean difference (MD) = 1.69, I² = 0.00 %, 95 %CI = 1.15-2.47, P = 0.01], PLOS (MD = -0.42, I² = 94.87 %, 95 %CI = -0.86-0.03, P = 0.07), duration of abdominal drain (MD = -1.23, I² = 96.96 %, 95 %CI = -2.04 to -0.42, P = 0.00), and hospital readmission (OR = 0.44, I² = 0.00 %, 95 %CI = 0.23-0.85, P = 0.01) compared to the non-ERAS group. CONCLUSION For patients with liver cancer treated with ERAS. The ERAS protocol reduces the percentage of overall postoperative complications. Moreover, ERAS does not increase the rate of blood transfusions, hospital readmission, reoperation, or mortality.
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Affiliation(s)
- Quan Lv
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Ying-Chun Xiang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan-Yu Qiu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, Beijing, , 100730, China
| | - Zheng Xiang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Chongqing Key Laboratory of Department of General Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Bär AK, Werkmeister R, Dort JC, Al-Nawas B. Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery. J Craniomaxillofac Surg 2024; 52:1244-1258. [PMID: 39183122 DOI: 10.1016/j.jcms.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/30/2024] [Accepted: 08/19/2024] [Indexed: 08/27/2024] Open
Abstract
The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.
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Affiliation(s)
- Anne-Kathrin Bär
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany; Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Richard Werkmeister
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Joseph C Dort
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Departments of Community Health Sciences and Oncology, Ohlson Research Initiative, Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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Wang B, Wang Y, Huang J, Wang P, Yao D, Huang Y, Zhou Z, Zhen L, Yu C, Xie T, Li Y. Impact of enhanced recovery after surgery (ERAS) on surgical site infection and postoperative recovery outcomes: a retrospective study of 1276 cases. Sci Rep 2024; 14:24055. [PMID: 39402102 PMCID: PMC11473544 DOI: 10.1038/s41598-024-74389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 09/25/2024] [Indexed: 10/17/2024] Open
Abstract
This retrospective observational study aimed to evaluate the incidence of surgical site infection (SSI) in the era of enhanced recovery after surgery (ERAS) and the effect of ERAS on postoperative outcomes. Totally 1,276 patients (565 in ERAS group and 711 in non-ERAS group) who underwent operations at the department of general surgery during 2017-2021 were included. Risk factors were identified via logistic regression analysis and meta-analysis of all relevant published studies was performed. Subsequently, propensity score matching was used to match different risk factors. Overall, 40 patients were diagnosed with SSI, and the pooled incidence of SSI was 3.13%. In total, 14 (2.48%) and 26 (3.66%) patients in the ERAS and non-ERAS groups, respectively, were diagnosed with SSI (P = 0.230). Among patients for whom the ERAS protocol was adopted, 7 independent risk factors of SSI were identified. After propensity score matching, in patients without SSI, the number of hospital days was significantly lower in the ERAS group than in the non-ERAS group (2 [2, 5] vs. 3 [2, 7], P = 0.005), whereas in patients with SSI, the number of hospital days was similar between the ERAS and non-ERAS groups. ERAS had no effect on the incidence of SSI but could significantly accelerate the discharge of uninfected patients. In the era of ERAS, SSI incidence was affected by the type of surgery; number of postoperative hospital days; type of incision; serum hemoglobin, total protein, and albumin levels; and antibiotic prophylaxis. Furthermore, these results will significantly affect the implementation of the ERAS protocol and optimal preoperative management.
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Affiliation(s)
- Baohong Wang
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yujie Wang
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Jingyan Huang
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Pengfei Wang
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Danhua Yao
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yuhua Huang
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Zhiyuan Zhou
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Lei Zhen
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Chaoran Yu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Tian Xie
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yousheng Li
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
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Kara S, Ozturk G, Demir Yetis Z, Korkut E, Aksungur N, Altundas N, Dogan N, Ozden K. The Effect of Enhanced Recovery After Surgery Protocol on Surgical Site Infections in Liver Transplantation. Surg Infect (Larchmt) 2024; 25:559-563. [PMID: 38959241 DOI: 10.1089/sur.2024.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Background: Liver surgeries are treatment modalities that require careful pre- and postoperative follow-up for both the surgeon and the patient. Infections are the leading causes of morbidity and mortality after liver transplantation. Infections are the most frequent cause of death between 30 and 180 days after liver transplantation. We aimed to investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on the prevention of infections in liver transplant patients. Patients and Methods: The study included patients who underwent liver transplantation in Ataturk University Organ Transplantation Center between 2017 and 2022. Two patient groups with and without ERAS were formed. Blood and urine cultures were collected retrospectively, and those with positive blood cultures for bacteremia were recorded as infection development. The development of infection between the two groups was statistically compared. Also, all patients' length of intensive care stay, length of hospital stay, and duration of antibiotic use were recorded. These parameters were compared between both groups. Results: There was a statistically significant difference between the two groups in terms of infection development (p: 0.01). There was a statistically significant difference between the two groups in terms of duration of antibiotic use and length of hospital stay (Mann-Whitney U test; p: 0.00, p: 0.04, respectively). There was no statistically significant difference between the two groups in terms of length of intensive care stay. Conclusion: We concluded that the introduction of an ERAS protocol was associated with fewer infections, thus shortening the duration of antibiotic therapy and length of hospital stay, although the standardization of the protocols is difficult, especially in liver transplants.
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Affiliation(s)
- S Kara
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - G Ozturk
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - Z Demir Yetis
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - E Korkut
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Aksungur
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Altundas
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Dogan
- Faculty of Medicine, Department of Anesthesiology, Ataturk University, Erzurum, Turkey
| | - K Ozden
- Faculty of Medicine, Department of Infectious Diseases, Ataturk University, Erzurum, Turkey
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23
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Blumenthal RN, Locke AR, Ben-Isvy N, Hasan MS, Wang C, Belanger MJ, Minhaj M, Greenberg SB. A Retrospective Comparison Trial Investigating Aggregate Length of Stay Post Implementation of Seven Enhanced Recovery After Surgery (ERAS) Protocols between 2015 and 2022. J Clin Med 2024; 13:5847. [PMID: 39407911 PMCID: PMC11477442 DOI: 10.3390/jcm13195847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 09/21/2024] [Accepted: 09/29/2024] [Indexed: 10/20/2024] Open
Abstract
(1) Introduction: Enhanced Recovery After Surgery (ERAS) protocols can create a cultural shift that will benefit patients by significantly reducing patient length of stay when compared to an equivalent group of surgical patients not following an ERAS protocol. (2) Methods: In this retrospective study of 2236 patients in a multi-center, community-based healthcare system, matching was performed based on a multitude of variables related to demographics, comorbidities, and surgical outcomes across seven ERAS protocols. These cohorts were then compared pre and post ERAS protocol implementation. (3) Results: ERAS protocols significantly reduced hospital length of stay from 3.0 days to 2.1 days (p <0.0001). Additional significant outcomes included reductions in opioid consumption from 40 morphine milligram equivalents (MMEs) to 20 MMEs (p <0.001) and decreased pain scores on postoperative day zero (POD 0), postoperative day one (POD 1), and postoperative day two (POD 2) when stratified into mild, moderate, and severe pain (p <0.001 on all three days). (4) Conclusions: ERAS protocols aggregately reduce hospital length of stay, pain scores, and opioid consumption.
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Affiliation(s)
- Rebecca N. Blumenthal
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Noah Ben-Isvy
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Muneeb S. Hasan
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Chi Wang
- Department of Biostatistics, Endeavor Health, Evanston, IL 60201, USA
| | - Matthew J. Belanger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL 60201, USA
- Department of Anesthesiology and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
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Schmoke N, Nemeh C, Gennell T, Schapiro D, Hiep-Catarino A, Alexander M, Chalphin AV, Crum RW, Holynskyj L, Kubacki T, Schechter WS, Zitsman J. Enhanced recovery after surgery improves clinical outcomes in adolescent bariatric surgery. Surg Obes Relat Dis 2024; 20:798-802. [PMID: 38653653 DOI: 10.1016/j.soard.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/10/2024] [Accepted: 03/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal approaches to optimize patient recovery and minimize complications. OBJECTIVES Our team evaluated clinical outcomes following the implementation of an ERAS protocol for adolescents undergoing metabolic and bariatric surgery. SETTING Academic hospital, New York, NY, USA. METHODS We performed a single-institution longitudinal assessment of adolescents who underwent laparoscopic vertical sleeve gastrectomy (VSG) between August 2021 and November 2022. Unpaired t-tests and Fisher's exact test were used to compare means between groups and categorical factors. RESULTS Forty-three patients were included in the study, 21 who participated in the ERAS protocol and 22 control patients. ERAS cohort was 52% females, with a median age of 17.5 years and a median body mass index (BMI) of 46.3 kg/m2. The non-ERAS cohort was 59% females, with a median age of 16.7 years and a median BMI of 44.0 kg/m2. There were no significant differences between baseline characteristics. Patients in the ERAS group had a shorter time to oral intake (10.7 hours versus 21.5 hours, P < .01), lower morphine milligram equivalents (18.2 versus 97.0, P < .01), and shorter length of stay (1.5 days versus 2.0 days, P = .01). There were no significant differences between return visits to the emergency department (ED) within 30 days (3 versus 2, P = .66) or readmissions (0 versus 1, P = 1.0). CONCLUSIONS The described ERAS protocol is safe and effective in adolescents undergoing laparoscopic VSG and is associated with shorter time to oral intake, reduced opioid requirements, and shorter hospital lengths of stay with no increase in return ED visits or readmissions.
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Affiliation(s)
- Nicholas Schmoke
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Christopher Nemeh
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Tania Gennell
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Dana Schapiro
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Ashley Hiep-Catarino
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Matthew Alexander
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Alexander V Chalphin
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Robert W Crum
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Leign Holynskyj
- Deparment of Nursing/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Tatiana Kubacki
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - William S Schechter
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York; Division of Pediatric Pain Medicine and Advanced Care Medicine, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York; Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Jeffrey Zitsman
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York.
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25
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Robella M, Vaira M, Ansaloni L, Asero S, Bacchetti S, Borghi F, Casella F, Coccolini F, De Cian F, di Giorgio A, Framarini M, Gelmini R, Graziosi L, Kusamura S, Lippolis P, Lo Dico R, Macrì A, Marrelli D, Sammartino P, Sassaroli C, Scaringi S, Tonello M, Valle M, Sommariva A. Enhanced recovery after surgery (ERAS) implementation in cytoreductive surgery (CRS) and hyperthermic IntraPEritoneal chemotherapy (HIPEC): Insights from Italian peritoneal surface malignancies expert centers. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108486. [PMID: 38971013 DOI: 10.1016/j.ejso.2024.108486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/12/2024] [Accepted: 06/12/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a complex procedure that involves extensive peritoneal and visceral resections followed by intraperitoneal chemotherapy. The Enhanced Recovery After Surgery (ERAS) program aims to achieve faster recovery by maintaining pre-operative organ function and reducing the stress response following surgery. A recent publication introduced dedicated ERAS guidelines for CRS and HIPEC with the aim of extending the benefits to patients with peritoneal surface malignancies. METHODS A survey was conducted among 21 Italian centers specializing in peritoneal surface malignancies (PSM) treatment to assess adherence to ERAS guidelines. The survey covered pre/intraoperative and postoperative ERAS items and explored attitudes towards ERAS implementation. RESULTS All centers completed the survey, demonstrating expertise in PSM treatment. However, less than 30 % of centers adopted ERAS protocols despite being aware of dedicated guidelines. Preoperative optimization was common, with variations in bowel preparation methods and fasting periods. Intraoperative normothermia control was consistent, but fluid management practices varied. Postoperative practices, including routine abdominal drain placement and NGT management, varied greatly among centers. The majority of respondents expressed an intention to implement ERAS, citing concerns about feasibility and organizational challenges. CONCLUSIONS The study concludes that Italian centers specialized in PSM treatment have limited adoption of ERAS protocols for CRS ± HIPEC, despite being aware of guidelines. The variability in practice highlights the need for standardized approaches and further evaluation of ERAS applicability in this complex surgical setting to optimize patient care.
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Affiliation(s)
- Manuela Robella
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy.
| | - Marco Vaira
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy
| | - Luca Ansaloni
- General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Salvatore Asero
- Soft Tissue U.O. Surgical Oncology-Soft Tissue Tumors, Dipartimento di Oncologia, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi Catania, 95123 Catania, Italy
| | - Stefano Bacchetti
- Advanced Surgical Oncology Center, ASUFC, DAME, University of Udine, 33100 Udine, Italy
| | - Felice Borghi
- Surgical Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo (TO), Italy
| | - Francesco Casella
- Upper GI Surgery Division, University of Verona, 37129 Verona, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | | | - Andrea di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Framarini
- General and Oncologic Department of Surgery, Morgagni - Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Roberta Gelmini
- General and Oncological Surgery Unit, AOU of Modena University of Modena and Reggio Emilia, Italy
| | - Luigina Graziosi
- University of Perugia, General and Emergency Surgery Department, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Dept. of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Piero Lippolis
- General and Peritoneal Surgery, Department of Surgery, Hospital University Pisa (AOUP), Pisa, Italy
| | - Rea Lo Dico
- Department of General and Emergency Surgery, S.Camillo-Forlanini Hospital, Rome, Italy
| | - Antonio Macrì
- Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
| | - Paolo Sammartino
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Cinzia Sassaroli
- UOSD Ricerca Integrata Medico Chirurgica nelle Neoplasie del Peritoneo, "Fondazione Giovanni Pascale" IRCCS, Naples, Italy
| | - Stefano Scaringi
- AOU Careggi, IBD Unit-Chirurgia Dell'Apparato Digerente, 50100 Firenze, Italy
| | - Marco Tonello
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Mario Valle
- Peritoneal Tumours Unit, IRCCS, Regina Elena Cancer Institute, 00144 Rome, Italy
| | - Antonio Sommariva
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
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Tian W, Luo L, Xu X, Zhao R, Tian T, Li W, Zhao Y, Yao Z. Nomogram for predicting intolerable postoperative early enteral nutrition following definitive surgery for small intestinal fistula: a cohort study. Int J Surg 2024; 110:5595-5604. [PMID: 38814286 PMCID: PMC11392138 DOI: 10.1097/js9.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/08/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND This study was designed to develop and validate a nomogram for predicting intolerable early enteral nutrition (EEN) following definitive surgery (DS) for small intestinal fistula. METHODS A total of 377 patients, recruited from January 2016 to September 2023, was randomly allocated into development ( n =251) and validation ( n =126) groups in a 2:1 ratio. Risk factors were identified using the nomogram. Its performance was assessed based on calibration, discrimination, and clinical utility, with validation confirming its effectiveness. RESULTS Of the 377 patients, 87 (23.1%) were intolerant to EEN, including 59 (23.1%) in the development cohort and 28 (22.1%) in the validation cohort ( P =0.84). Four factors were identified as predictive of intolerable EEN: severe abdominal adhesion, deciliter of blood loss during DS, human serum albumin (Alb) input >40 g during and within 48 h post-DS, and the visceral fat area (VFA)/total abdominal muscle area index (TAMAI) ratio. The model demonstrated excellent discrimination, with a C-index of 0.79 (95% CI: 0.74-0.87, including internal validation) and robust calibration. In the validation cohort, the nomogram showed strong discrimination (C-index=0.77; 95% CI: 0.64-0.87) and solid calibration. Decision curve analysis affirmed the nomogram's clinical utility. CONCLUSION This research introduces a nomogram that enables the individualized prediction of intolerable EEN following DS for small intestinal fistula, demonstrating a possible clinical utility.
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Affiliation(s)
- Weiliang Tian
- Research Institute of General Surgery, Jinling Hospital, Nanjing Medical University
| | - Lei Luo
- Department of General Surgery, The Affiliated Zhuzhou Hospital Central South University, Zhuzhou
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Tao Tian
- Department of General Surgery, Shanghai 9th Hospital, Shanghai
| | - Wuhan Li
- Department of General Surgery, Anhui Provincial Hospital, Hefei, Anhui, People’s Republic of China
| | - Yunzhao Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
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Li YQ, Liu Y, Peng ZQ, Fang R, Xu HY. Enhanced recovery after surgery-based nursing in older patients with postoperative intestinal obstruction after gastric cancer surgery: A retrospective study. World J Clin Cases 2024; 12:4983-4991. [DOI: 10.12998/wjcc.v12.i22.4983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Gastric cancer-related morbidity and mortality rates are high in China. Patients who have undergone gastric cancer surgery should receive six cycles of chemotherapy according to their condition. During this period, intestinal obstruction is likely to occur. Electrolyte balance disorders, peritonitis, intestinal necrosis, and even hypovolemic shock and septic shock can seriously affect the physical and mental recovery of patients and threaten their health and quality of life (QoL).
AIM To quantitatively explore the effects of enhanced recovery after surgery (ERAS)–based nursing on anxiety, depression, and QoL of elderly patients with postoperative intestinal obstruction after gastric cancer.
METHODS The clinical data of 129 older patients with intestinal obstruction after gastric cancer surgery who were treated and cared for in our hospital between January 2019 and December 2021 were examined retrospectively. Nine patients dropped out because of transfer, relocation, or death. According to the order of admissions, the patients were categorized into either a comparison group or an observation group according to the random number table, with 60 cases in each group.
RESULTS After nursing care, the observation group required significantly less time to eat for the first time, recover bowel sounds, pass gas, and defecate than the comparison group (P < 0.05). No significant difference was noted in nutrition-related indicators between the two groups before care. Before care, the Symptom Check List-90 scores between the two groups were comparable, whereas anxiety, depression, paranoia, fear, hostility, obsession, somatization, interpersonal sensitivity, and psychotic scores were significantly lower in the observation group after care (P < 0.05). The QoL scores between the two groups before care did not differ significantly. After care, the physical, social, physiological, and emotional function scores; mental health score; vitality score; and general health score were significantly higher in the observation group, whereas the somatic pain score was significantly lower in the observation group (P < 0.05).
CONCLUSION ERAS-based nursing combined with conventional nursing interventions can effectively improve patient’s QoL, negative emotions, and nutritional status; accelerate the time to first ventilation; and promote intestinal function recovery in elderly patients with postoperative intestinal obstruction after gastric cancer surgery.
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Affiliation(s)
- Yu-Qin Li
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Ying Liu
- Department of Thoracic Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430079, Hubei Province, China
| | - Zhu-Qing Peng
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Rong Fang
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
| | - Hai-Yan Xu
- Department of Gastroenterology, Wuhan Fourth Hospital, Wuhan 430033, Hubei Province, China
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Park JO, Lafaro K, Hagendoorn J, Melstrom L, Gerhards MF, Görgec B, Marsman HA, Thornblade LW, Pilz da Cunha G, Yang FF, Labadie KP, Sham JG, Swijnenburg RJ, He J, Fong Y. Outpatient and Ambulatory Extended Recovery Robotic Hepatectomy: Multinational Study of 307 Cases. J Am Coll Surg 2024; 239:61-67. [PMID: 38770933 DOI: 10.1097/xcs.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure. STUDY DESIGN We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions. RESULTS A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m 2 (14 to 63 kg/m 2 ). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess. CONCLUSIONS Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments.
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Affiliation(s)
- James O Park
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Kelly Lafaro
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Lafaro, He)
| | - Jeroen Hagendoorn
- Department of Surgical Oncology, University Medical Center, Utrecht, The Netherlands (Hagendoorn)
| | - Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA (Melstrom, Fong)
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (Gerhards, Marsman)
| | - Burak Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Hendrik A Marsman
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (Gerhards, Marsman)
| | - Lucas W Thornblade
- Department of Surgical Oncology, University of California San Fransisco, San Fransisco, CA (Thornblade)
| | - Gabriela Pilz da Cunha
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Frank F Yang
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Kevin P Labadie
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Jonathan G Sham
- From the Division of General Surgery, University of Washington, Seattle, WA (Park, Yang, Labadie, Sham)
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands (Görgec, Pilz da Cunha, Swijnenburg)
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Lafaro, He)
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA (Melstrom, Fong)
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29
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Berikashvili LB, Yadgarov MY, Kuzovlev AN, Smirnova AV, Kadantseva KK, Kuznetsov IV, Polyakov PA, Likhvantsev VV. Adductor Canal Block Versus Femoral Nerve Block in Total Knee Arthroplasty: Network Meta-Analysis. Clin J Pain 2024; 40:447-457. [PMID: 38561898 DOI: 10.1097/ajp.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The quality of postoperative analgesia in total knee arthroplasty is crucial for patient recovery, rehabilitation, and hospital stay duration. In line with the above, а single-shot adductor canal block has been considered as an improved method over continuous femoral nerve block. However, continuous adductor canal block and single-shot femoral nerve block have been not adequately addressed in the discussion. This study aimed to compare the effectiveness of various types of adductor and femoral nerve blocks on clinically relevant outcomes in patients following total knee arthroplasty. METHODS A systematic review and network meta-analysis were conducted following "PRISMA-NMA" and Cochrane Handbook guidelines. The eligibility criteria included randomized trials and, where these were lacking for a comparison, nonrandomized studies involving adults undergoing primary total knee arthroplasty, comparing single-shot adductor canal block, continuous adductor canal block, single-shot femoral nerve block, and continuous femoral nerve block. RESULTS A total of 36 studies involving 3308 patients were included. Single-shot adductor canal block showed higher pain scores and opioid consumption but better functional recovery at 24 h compared with continuous femoral nerve block. However, this trend vanishes by the 48 h assessment postsurgery. Continuous adductor canal block required higher opioid consumption but better functional recovery and shorter hospital stay compared with continuous femoral nerve block. Single-shot adductor canal block showed higher pain scores but comparable opioid consumption and functional recovery to continuous adductor canal block. DISCUSSION The shift from continuous femoral nerve block to single-shot adductor canal block as the preferred method for pain relief after total knee arthroplasty may be premature. While the latter improves mobility, it falls short in pain control and does not shorten hospital stays. Continuous adductor canal block shows promise but is currently underappreciated, and single-shot femoral nerve block is often overshadowed by other techniques in regional anesthesia. Further high-quality, multicenter randomized controlled trials are needed to validate these findings.
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Affiliation(s)
- Levan B Berikashvili
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- Vladimirsky Moscow Regional Research and Clinical Institute
| | - Mikhail Ya Yadgarov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Artem N Kuzovlev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Anastasia V Smirnova
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- City Clinical Oncological Hospital No. 1
| | - Kristina K Kadantseva
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- A. Loginov Moscow Clinical Scientific Centre
| | - Ivan V Kuznetsov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Petr A Polyakov
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
| | - Valery V Likhvantsev
- Federal Research and Clinical Centre of Intensive Care Medicine and Rehabilitology
- First Moscow State Medical University, Moscow, Russia
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30
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Bezu L, Akçal Öksüz D, Bell M, Buggy D, Diaz-Cambronero O, Enlund M, Forget P, Gupta A, Hollmann MW, Ionescu D, Kirac I, Ma D, Mokini Z, Piegeler T, Pranzitelli G, Smith L, The EuroPeriscope Group. Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review. Cancers (Basel) 2024; 16:2304. [PMID: 39001366 PMCID: PMC11240822 DOI: 10.3390/cancers16132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.
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Affiliation(s)
- Lucillia Bezu
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Département d'Anesthésie, Chirurgie et Interventionnel, Gustave Roussy, 94805 Villejuif, France
- U1138 Metabolism, Cancer and Immunity, Gustave Roussy, 94805 Villejuif, France
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Dilara Akçal Öksüz
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Clinic for Anesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Medicine, Marienhaus Klinikum Hetzelstift, 67434 Neustadt an der Weinstrasse, Germany
- ESAIC Mentorship Program, BE-1000 Brussels, Belgium
| | - Max Bell
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Solna, 17176 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, 17176 Stockholm, Sweden
| | - Donal Buggy
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Division of Anaesthesiology, Mater Misericordiae University Hospital, D07 WKW8 Dublin, Ireland
- School of Medicine, University College, D04 V1W8 Dublin, Ireland
| | - Oscar Diaz-Cambronero
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, 46026 Valencia, Spain
- Perioperative Medicine Research, Health Research Institute Hospital la Fe, 46026 Valencia, Spain
- Faculty of Medicine, Department of Surgery, University of Valencia, 46010 Valencia, Spain
| | - Mats Enlund
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Center for Clinical Research, Uppsala University, SE-72189 Västerås, Sweden
- Department of Anesthesia & Intensive Care, Västmanland Hospital, SE-72189 Västerås, Sweden
| | - Patrice Forget
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZN, UK
- Department of Anaesthesia, NHS Grampian, University of Aberdeen, Aberdeen AB25 2ZN, UK
- Pain and Opioids after Surgery (PANDOS) ESAIC Research Group, European Society of Anaesthesiology and Intensive Care, 1000 Brussels, Belgium
- IMAGINE UR UM 103, Anesthesia Critical Care, Emergency and Pain Medicine Division, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| | - Anil Gupta
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Physiology and Pharmacology, Karolinska Institute, 17176 Stockholm, Sweden
| | - Markus W Hollmann
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology, Amsterdam UMC, 1100 DD Amsterdam, The Netherlands
| | - Daniela Ionescu
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesia and Intensive Care, University of Medicine and Pharmacy "Iuliu Hatieganu", 400012 Cluj-Napoca, Romania
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Iva Kirac
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Genetic Counselling Unit, University Hospital for Tumors, Sestre Milosrdnice University Hospital Centre, 10000 Zagreb, Croatia
| | - Daqing Ma
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London SW10 9NH, UK
- Department of Anesthesiology, Perioperative and Systems Medicine Laboratory, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Zhirajr Mokini
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- ESAIC Mentorship Program, BE-1000 Brussels, Belgium
- Clinique du Pays de Seine, 77590 Bois le Roi, France
| | - Tobias Piegeler
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, University of Leipzig Medical Center, 04275 Leipzig, Germany
| | - Giuseppe Pranzitelli
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, San Timoteo Hospital, 86039 Termoli, Italy
| | - Laura Smith
- EuroPeriscope, ESA-IC Onco-Anaesthesiology Research Group, B-1000 Brussels, Belgium
- Department of Anaesthesia, NHS Grampian, University of Aberdeen, Aberdeen AB25 2ZN, UK
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZN, UK
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31
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Weigle CA, Beetz O, Wiemann BA, Tessmer P, Störzer S, Cammann S, Vondran FWR, Oldhafer F, Schmelzle M, Richter N. Resection of intrahepatic cholangiocarcinoma in octogenarians: a single-center analysis. Discov Oncol 2024; 15:224. [PMID: 38865024 PMCID: PMC11169410 DOI: 10.1007/s12672-024-01065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024] Open
Abstract
The rapidly aging population in industrialized countries comes with an increased incidence of intrahepatic cholangiocarcinoma (iCC) which presents new challenges for oncological treatments especially in elderly patients. Thus, the question arises to what extent the benefit of surgical resections, as the only curative treatment option, outweighs possible perioperative risks in patients ≥ 80 years of age (octogenarians). We therefore retrospectively analyzed 311 patients who underwent resection for iCC at Hannover Medical School between January 1996 and December 2022. In total, there were 11 patients older than 80 years in our collective. Despite similar tumor size, octogenarians underwent comparatively less extensive surgery (54.5% major resections in octogenarians vs. 82.7% in all other patients; p = 0.033) with comparable rates of lymphadenectomy and tumor-free resection margins. Furthermore, we did not observe increased major postoperative morbidity (Clavien-Dindo ≥ IIIa complications: 27.3% vs. 34.3% in all other patients; p = 0.754) or mortality (estimated 1-year OS of 70.7% vs. 72.5% in all other patients, p = 0.099). The length of intensive care unit (ICU) or intermediate care unit (IMC) stay was significantly longer in octogenarians, however, with a comparable length in total hospital stay. The estimated overall survival (OS) did also not differ significantly, although a trend towards reduced long-term survival was observed (14.5 months vs. 28.03 months in all other patients; p = 0.099). In conclusion, primary resection is a justifiable and safe therapeutic option even in octogenarians but requires an even more thorough preoperative patient selection.
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Affiliation(s)
- Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Bengt A Wiemann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Philipp Tessmer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Simon Störzer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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32
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De Gasperi A, Petrò L, Amici O, Scaffidi I, Molinari P, Barbaglio C, Cibelli E, Penzo B, Roselli E, Brunetti A, Neganov M, Giacomoni A, Aseni P, Guffanti E. Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist. World J Crit Care Med 2024; 13:92751. [PMID: 38855273 PMCID: PMC11155507 DOI: 10.5492/wjccm.v13.i2.92751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/15/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024] Open
Abstract
Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.
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Affiliation(s)
- Andrea De Gasperi
- Former Head, Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Laura Petrò
- AR1, Ospedale Papa Giovanni 23, Bergamo 24100, Italy
| | - Ombretta Amici
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Ilenia Scaffidi
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Pietro Molinari
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Caterina Barbaglio
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Eva Cibelli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Beatrice Penzo
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Elena Roselli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Andrea Brunetti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Maxim Neganov
- Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, Rozzano 20089, Italy
| | - Alessandro Giacomoni
- Chirurgia Oncologica Miniinvasiva, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Paolo Aseni
- Dipartimento di Medicina d’Urgenza ed Emergenza, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milano 20163, MI, Italy
| | - Elena Guffanti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
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33
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Dyas AR, Stuart CM, Bronsert MR, Kelleher AD, Bata KE, Cumbler EU, Erickson CJ, Blum MG, Vizena AS, Barker AR, Funk L, Sack K, Abrams BA, Randhawa SK, David EA, Mitchell JD, Weyant MJ, Scott CD, Meguid RA. Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System. Ann Surg 2024; 279:1062-1069. [PMID: 38385282 PMCID: PMC11087203 DOI: 10.1097/sla.0000000000006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. BACKGROUND The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported. METHODS This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders. RESULTS There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05). CONCLUSIONS Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.
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Affiliation(s)
- Adam R. Dyas
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Christina M. Stuart
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R. Bronsert
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyson D. Kelleher
- Department of Quality and Safety, University of Colorado School of Medicine, Aurora, CO
| | - Kyle E. Bata
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ethan U. Cumbler
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Matthew G. Blum
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs, CO
| | - Annette S. Vizena
- Department of Anesthesiology, UCHealth Poudre Valley Hospital. Fort Collins, CO
| | - Alison R. Barker
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Lauren Funk
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Karishma Sack
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin A. Abrams
- Department of Anesthesiology and Critical Care, University of Colorado School of Medicine, Aurora, CO
| | - Simran K. Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth A. David
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - John D. Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Christopher D. Scott
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert A. Meguid
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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34
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Fichtinger RS, Aldrighetti LA, Abu Hilal M, Troisi RI, Sutcliffe RP, Besselink MG, Aroori S, Menon KV, Edwin B, D'Hondt M, Lucidi V, Ulmer TF, Díaz-Nieto R, Soonawalla Z, White S, Sergeant G, Olij B, Ratti F, Kuemmerli C, Scuderi V, Berrevoet F, Vanlander A, Marudanayagam R, Tanis P, Dewulf MJ, Dejong CH, Eminton Z, Kimman ML, Brandts L, Neumann UP, Fretland ÅA, Pugh SA, van Breukelen GJ, Primrose JN, van Dam RM. Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. J Clin Oncol 2024; 42:1799-1809. [PMID: 38640453 PMCID: PMC11107897 DOI: 10.1200/jco.23.01019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/13/2023] [Accepted: 01/17/2024] [Indexed: 04/21/2024] Open
Abstract
PURPOSE To compare outcomes after laparoscopic versus open major liver resection (hemihepatectomy) mainly for primary or metastatic cancer. The primary outcome measure was time to functional recovery. Secondary outcomes included morbidity, quality of life (QoL), and for those with cancer, resection margin status and time to adjuvant systemic therapy. PATIENTS AND METHODS This was a multicenter, randomized controlled, patient-blinded, superiority trial on adult patients undergoing hemihepatectomy. Patients were recruited from 16 hospitals in Europe between November 2013 and December 2018. RESULTS Of the 352 randomly assigned patients, 332 patients (94.3%) underwent surgery (laparoscopic, n = 166 and open, n = 166) and comprised the analysis population. The median time to functional recovery was 4 days (IQR, 3-5; range, 1-30) for laparoscopic hemihepatectomy versus 5 days (IQR, 4-6; range, 1-33) for open hemihepatectomy (difference, -17.5% [96% CI, -25.6 to -8.4]; P < .001). There was no difference in major complications (laparoscopic 24/166 [14.5%] v open 28/166 [16.9%]; odds ratio [OR], 0.84; P = .58). Regarding QoL, both global health status (difference, 3.2 points; P < .001) and body image (difference, 0.9 points; P < .001) scored significantly higher in the laparoscopic group. For the 281 (84.6%) patients with cancer, R0 resection margin status was similar (laparoscopic 106 [77.9%] v open 122 patients [84.1%], OR, 0.60; P = .14) with a shorter time to adjuvant systemic therapy in the laparoscopic group (46.5 days v 62.8 days, hazard ratio, 2.20; P = .009). CONCLUSION Among patients undergoing hemihepatectomy, the laparoscopic approach resulted in a shorter time to functional recovery compared with open surgery. In addition, it was associated with a better QoL, and in patients with cancer, a shorter time to adjuvant systemic therapy with no adverse impact on cancer outcomes observed.
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Affiliation(s)
- Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
- Department of Surgery, Poliambulanza Hospital, Brescia, Italy
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Transplantation Service, Federico II University, Naples, Italy
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Robert P. Sutcliffe
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Somaiah Aroori
- Department of Surgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Krishna V. Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bjørn Edwin
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge, Kortrijk, Belgium
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Tom F. Ulmer
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rafael Díaz-Nieto
- Department of Hepato-Biliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Steve White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Gregory Sergeant
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Christoph Kuemmerli
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Vincenzo Scuderi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of Surgery, Free University Hospital, AZ Jette Hospital, Brussels, Belgium
| | - Ravi Marudanayagam
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pieter Tanis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Maxime J.L. Dewulf
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cornelis H.C. Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Deceased
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Merel L. Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ulf P. Neumann
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, University Hospital Essen, Essen, Germany
| | - Åsmund A. Fretland
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gerard J.P. van Breukelen
- Department of Methodology and Statistics, CAPHRI Care and Public Health Research Institute Maastricht University, Maastricht, the Netherlands
| | - John N. Primrose
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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Moosburner S, Dahlke PM, Neudecker J, Hillebrandt KH, Koch PF, Knitter S, Ludwig K, Kamali C, Gül-Klein S, Raschzok N, Schöning W, Sauer IM, Pratschke J, Krenzien F. From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery. Langenbecks Arch Surg 2024; 409:137. [PMID: 38653917 PMCID: PMC11039530 DOI: 10.1007/s00423-024-03329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses. METHODS A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations. RESULTS 537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640. CONCLUSIONS Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.
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Affiliation(s)
- Simon Moosburner
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Paul M Dahlke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Pia F Koch
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sebastian Knitter
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kristina Ludwig
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Can Kamali
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany.
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Muetterties CE, Taylor JM, Kaeding DE, Rosales Morales R, Nguyen AV, Kwan L, Tseng CY, Delong MR, Festekjian JH. Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5732. [PMID: 38623445 PMCID: PMC11018206 DOI: 10.1097/gox.0000000000005732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 04/17/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.
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Affiliation(s)
- Corbin E. Muetterties
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Diana E. Kaeding
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ricardo Rosales Morales
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Anissa V. Nguyen
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Lorna Kwan
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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Delabays C, Demartines N, Joliat GR, Melloul E. Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:24. [PMID: 38561792 PMCID: PMC10983761 DOI: 10.1186/s13741-024-00375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care. METHODS A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates. RESULTS After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure. CONCLUSION In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.
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Affiliation(s)
- Constant Delabays
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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Wu R, Robayo V, Nguyen DT, Chan EY, Chihara R, Huang HJ, Graviss EA, Kim MP. Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients. Surg Endosc 2024; 38:2134-2141. [PMID: 38443500 DOI: 10.1007/s00464-024-10719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.
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Affiliation(s)
- Rebecca Wu
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Edward Y Chan
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Howard J Huang
- Division of Pulmonary Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, FACS. 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
| | - Min P Kim
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA.
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Voigt KR, de Graaff MR, Verhoef C, Kazemier G, Swijneburg RJ, Mieog JSD, Derksen WJM, Buis CI, Gobardhan PD, Dulk MD, van Dam RM, Liem MSL, Leclercq WKG, Bosscha K, Belt EJT, Vermaas M, Kok NFM, Patijn GA, Marsman HM, van den Boezem PB, Klaase JM, Grünhagen DJ. Association of modified textbook outcome and overall survival after surgery for colorectal liver metastases: A nationwide analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107972. [PMID: 38278128 DOI: 10.1016/j.ejso.2024.107972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Textbook outcome (TO) represents a multidimensional quality measurement, encompassing the desirable short-term outcomes following surgery. This study aimed to investigate whether achieving TO after resection of colorectal liver metastases (CRLM) surgery is related to better overall survival (OS) in a national cohort. METHOD Data was retrieved from the Dutch Hepato Biliary Audit. A modified definition of TO (mTO) was used because readmissions were only recorded from 2019. mTO was achieved when no severe postoperative complications, mortality, prolonged length of hospital stay, occurred and when adequate surgical resection margins were obtained. To compare outcomes of patients with and without mTO and reduce baseline differences between both groups propensity score matching (PSM) was used for patients operated on between 2014 and 2018. RESULTS Out of 6525 eligible patients, 81 % achieved mTO. For the cohort between 2014 and 2018, those achieving mTO had a 5-year OS of 46.7 % (CI 44.8-48.6) while non-mTO patients had a 5-year OS of 33.7 % (CI 29.8-38.2), p < 0.001. Not achieving mTO was associated with a worse OS (aHR 1.34 (95 % CI 1.17-1.53), p < 0.001. Median follow-up was 76 months., PSM assigned 519 patients to each group. In the PSM cohort patients achieving mTO, 5-year OS was 43.6 % (95 % CI 39.2-48.5) compared to 36.4 % (95 % CI 31.9-41.2) in patients who did not achieve mTO, p = 0.006. CONCLUSION Achieving mTO is associated with improved long-term survival. This emphasizes the importance of optimising perioperative care and reducing postoperative complications in surgical treatment of CRLM.
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Affiliation(s)
- Kelly R Voigt
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Michelle R de Graaff
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands; Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rutger J Swijneburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Carlijn I Buis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Medical Centre, Breda, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Nutrim - School of Nutrition and Translational Research in Metabolism, Maastricht University, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's, Hertogenbosch, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle Aan de Ijssel, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - H M Marsman
- Department of Surgery, Onze Lieve Vrouwen Hospital, Amsterdam, the Netherlands
| | | | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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Çetin B, Çilesiz NC, Ozkan A, Onuk Ö, Kır G, Balci MBC, Özdemir E. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Length of Hospital Stay in Radical Cystectomy: A Prospective Randomized Controlled Study. Cureus 2024; 16:e55460. [PMID: 38571847 PMCID: PMC10988186 DOI: 10.7759/cureus.55460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/05/2024] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols challenge the conventional and rigid methods of surgery and anesthesia and bring about novel changes that are quite drastic. The core principle of the protocol is to minimize the metabolic disturbance caused by surgical injury, facilitate the restoration of functions in a brief period, and promote the resumption of normal activity at the earliest. To compare the outcomes of ERAS and standard protocol for patients who have undergone radical cystectomy (RC) with ileal conduit urinary diversion. This prospective randomized controlled study was performed between 2015 and 2023. The 77 patients were divided into two groups ERAS (n=39) and Standard (n=38) by sequential randomization. These two groups are divided according to protocols of bowel preparation, anesthesia, and postoperative nutrition. The clinical and demographic characteristics of the patients, and the American Society of Anesthesiologists (ASA) and Eastern Cooperative Oncology Group (ECOG) scores were recorded. Perioperative findings, the degree of complications according to the Clavien-Dindo classification, and the total cost of treatment were recorded and analyzed. Length of hospital stay (18.82±9.25 day vs 27.34±15.05 day), and cost of treatment (2168,2±933$ 2879±1806$) were higher in the standard group. The rate of nausea and vomiting and the use of antiemetics were higher in the ERAS group compared to the standard group. In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.
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Affiliation(s)
- Buğra Çetin
- Urology, Altınbaş University Medicalpark Bahçelievler Hospital, Istanbul, TUR
| | | | | | - Özkan Onuk
- Urology, Biruni University Hospital, Istanbul, TUR
| | - Gülay Kır
- Anesthesiology and Reanimation, Koç University, Istanbul, TUR
| | - M B Can Balci
- Urology, Taksim Training and Research Hospital, Istanbul, TUR
| | - Enver Özdemir
- Urology, Gaziosmanpaşa Training and Research Hospital, Istanbul, TUR
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Davey MG, Donlon NE, Fearon NM, Heneghan HM, Conneely JB. Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials. Obes Surg 2024; 34:778-789. [PMID: 38273146 PMCID: PMC10899423 DOI: 10.1007/s11695-024-07072-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery. AIM To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC). METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC. CONCLUSION ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Noel E Donlon
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Naomi M Fearon
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Helen M Heneghan
- Surgical Professorial Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - John B Conneely
- Department of Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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Sánchez-Pérez B, Ramia JM. Does enhanced recovery after surgery programs improve clinical outcomes in liver cancer surgery? World J Gastrointest Oncol 2024; 16:255-258. [PMID: 38425397 PMCID: PMC10900164 DOI: 10.4251/wjgo.v16.i2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/11/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
Enhanced recovery after surgery (ERAS) programs have been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016 and the new recommendations in 2022. Liver surgery is usually performed in oncological patients (liver metastasis, hepatocellular carcinoma, cholangiocarcinoma, etc.), but the real impact of liver surgery ERAS programs in oncological outcomes is not clearly defined. Theoretical advantages of ERAS programs are: ERAS decreases postoperative complication rates and has been demonstrated a clear relationship between complications and oncological outcomes; a better and faster postoperative recovery should let oncologic teams begin chemotherapeutic regimens on time; prehabilitation and nutrition actions before surgery should also improve the performance status of the patients receiving chemotherapy. So, ERAS could be another way to improve our oncological results. We will discuss the literature about liver surgery ERAS focusing on its oncological implications and future investigations projects.
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Affiliation(s)
- Belinda Sánchez-Pérez
- Department of General, Digestive and Transplantation Surgery, University Regional Hospital, Málaga 29010, Málaga, Spain
| | - José M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante 03010, Spain
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Zhang M, Cai P. Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery. Medicine (Baltimore) 2024; 103:e36929. [PMID: 38335409 PMCID: PMC10860964 DOI: 10.1097/md.0000000000036929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/19/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024] Open
Abstract
Investigating the applying effects of the enhanced recovery after surgery (ERAS) in the perioperative period of elderly lung cancer patients undergoing the surgery. We randomly selected 98 elderly patients with lung cancer who were admitted to our hospital and underwent surgery from January 2022 to September 2023 as study subjects. The control group received conventional care during the perioperative period, and the intervention group received ERAS-guided care measures. The differences in perioperative-related indices, pulmonary function, pain level, inflammatory factors, and postoperative complication rates between these 2 groups were compared. The postoperative extubation time, the activity time since getting out of bad and hospital stay were lower in the observation group than those in the control group (P < .05). At 3 days postoperatively, the FEV1, forced vital capacity and maximum ventilation volume of these 2 groups were lower than those of their same groups before surgery, and those of the observation group were higher than those of the control group (P < .05). At 3 days postoperatively, the numerical rating scale in both groups were lower than those of their same groups at 6 hours postoperatively, and the numerical rating scale of the observation group was lower than that of the control group (P < .05). At 3 days postoperatively, tumor necrosis factor-α, IL-6, and CRP in both groups were higher than those in their same groups before surgery, and those of the observation group was lower than those of the control group (P < .05). The incidence of postoperative complications in the observation group was lower than that in the control group (P < .05). ERAS applied in the perioperative period of elderly lung cancer patients undergoing surgery can shorten the hospital stay, promote the postoperative recovery on pulmonary function, alleviate inflammation, and reduce the risk of postoperative complications.
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Affiliation(s)
- Ming Zhang
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Ping Cai
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
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Clet A, Guy M, Muir JF, Cuvelier A, Gravier FE, Bonnevie T. Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study. Healthcare (Basel) 2024; 12:436. [PMID: 38391811 PMCID: PMC10887527 DOI: 10.3390/healthcare12040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.
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Affiliation(s)
- Augustin Clet
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Marin Guy
- Centre Aquitain Du Dos, Hôpital Privé Saint-Martin, F-33600 Pessac, France
| | - Jean-François Muir
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Antoine Cuvelier
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, F-76000 Rouen, France
| | - Francis-Edouard Gravier
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
| | - Tristan Bonnevie
- Université Rouen Normandie, Normandie Univ, GRHVN UR 3830, F-76000 Rouen, France
- ADIR Association, Rouen University Hospital, F-76000 Rouen, France
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Schwenk W, Flemming S, Girona-Johannkämper M, Wendt W, Darwich I, Strey C. [Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:148-156. [PMID: 37947802 DOI: 10.1007/s00104-023-01986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals. METHODS Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay. RESULTS Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ. CONCLUSION Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.
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Affiliation(s)
- Wolfgang Schwenk
- Gesellschaft für Optimiertes perioperatives Management, GOPOM GmbH, Düsseldorf, Deutschland.
- Gesellschaft für Optimiertes Perioperatives Management GOPOPM GmbH, Oberlörickerstr. 390b, 40547, Düsseldorf, Deutschland.
| | - Sven Flemming
- Universitätsklinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Wolfgang Wendt
- Viszeralchirurgie / Proktologie, Diakonissenkrankenhaus Dresden, Dresden, Deutschland
| | - Ibrahim Darwich
- Klinik für Allgemein- und Viszeralchirurgie, St. Marien Krankenhaus Siegen, Siegen, Deutschland
| | - Christoph Strey
- Klinik für Allgemein- und Viszeralchirurgie, DRK Krankenhaus Clementinenhaus, Hannover, Deutschland
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Pang TS, Cao LP. Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A meta-analysis spanning 2004 to 2022. World J Gastrointest Surg 2024; 16:215-227. [PMID: 38328319 PMCID: PMC10845291 DOI: 10.4240/wjgs.v16.i1.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Postoperative complications remain a paramount concern for surgeons and healthcare practitioners. AIM To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system's efficacy in predicting postoperative complications following abdominal surgery. METHODS A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ2 tests assessing heterogeneity (P value). RESULTS Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)]. CONCLUSION In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.
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Affiliation(s)
- Tian-Shu Pang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Li-Ping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
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Grass F, Roth-Kleiner M, Demartines N, Agri F. Day Admission Surgery Program in a Prospective Payment System: What Are the Financial Incentives? Health Serv Insights 2024; 17:11786329231222970. [PMID: 38250650 PMCID: PMC10798120 DOI: 10.1177/11786329231222970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
Background Day admission surgery (DAS) is meant to provide a better in-hospital experience for patients and to save costs by reducing the length of stay. However, in a prospective payment system, it may also reduce the reimbursement amount, leading to unintended incentives for hospitals. Methods Over a 4-month period in 2021 and based on predefined clinical and logistic criteria, patients from different surgical sub-specialties were identified to follow the institutional DAS program. Revenue-analysis was performed, considering the Swiss diagnosis-related group (SwissDRG) prospective payment policy. Revenue with DAS program was compared to revenue if patients were admitted the day prior surgery (No DAS) using nonparametric pooled bootstrap t-test. All other costs considered identical, an estimation of the average cost spared due to the avoidance of pre-operative hospitalization in the DAS setting was carried out using a micro-costing approach. Results Overall, 105 inpatients underwent DAS over the study period, totaling a revenue of CHF 1 209 840. Among them, 25 patients (24%) were low outliers due to the day spared from the DAS program and triggering a mean (SD) financial discount of Swiss Francs (CHF) 4192 (2835), yielding a total amount of CHF 105 435. DAS revealed a mean revenue of CHF 7320 (656), compared to CHF 11 510 (1108) if patients were admitted the day before surgery (No DAS, P = .007). Conclusion In a PPS, anticipation of financial penalties when implementing a DAS for all-comers is key to prevent an imbalance of the hospital equation if no financial criteria are used to select eligible patients. Promptly revising workflow to maintain constant fixed costs for a greater number of patients may be a valuable hedging strategy.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Matthias Roth-Kleiner
- Medical Direction, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Department of Administration and Finance. Lausanne University Hospital, Lausanne, Switzerland
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Pi S, Masterson J, Ma SP, Corbin CK, Milstein A, Chen JH. Using Case Mix Index within Diagnosis-Related Groups to Evaluate Variation in Hospitalization Costs at a Large Academic Medical Center. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2024; 2023:1201-1208. [PMID: 38222372 PMCID: PMC10785921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
In analyzing direct hospitalization cost and clinical data from an academic medical center, commonly used metrics such as diagnosis-related group (DRG) weight explain approximately 37% of cost variability, but a substantial amount of variation remains unaccounted for by case mix index (CMI) alone. Using CMI as a benchmark, we isolate and target individual DRGs with higher than expected average costs for specific quality improvement efforts. While DRGs summarize hospitalization care after discharge, a predictive model using only information known before admission explained up to 60% of cost variability for two DRGs with a high excess cost burden. This level of variability likely reflects underlying patient factors that are not modifiable (e.g., age and prior comorbidities) and therefore less useful for health systems to target for intervention. However, the remaining unexplained variation can be inspected in further studies to discover operational factors that health systems can target to improve quality and value for their patients. Since DRG weights represent the expected resource consumption for a specific hospitalization type relative to the average hospitalization, the data-driven approach we demonstrate can be utilized by any health institution to quantify excess costs and potential savings among DRGs.
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Affiliation(s)
- Selina Pi
- Department of Biomedical Data Science, Stanford, California, USA
| | | | - Stephen P Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Conor K Corbin
- Department of Biomedical Data Science, Stanford, California, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, CA, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
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Hsiao WL, Wu YC, Tai HC. Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery. Sci Rep 2024; 14:302. [PMID: 38167861 PMCID: PMC10762210 DOI: 10.1038/s41598-023-50881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.
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Affiliation(s)
- Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Cheng Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan
| | - Hao-Chih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan.
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Dahlke PM, Benzing C, Lurje G, Malinka T, Raschzok N, Kamali C, Gül-Klein S, Schöning W, Hillebrandt KH, Pratschke J, Neudecker J, Krenzien F. Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study. BJS Open 2024; 8:zrad147. [PMID: 38242574 PMCID: PMC10799324 DOI: 10.1093/bjsopen/zrad147] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/30/2023] [Accepted: 10/31/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Adherence to enhanced recovery after surgery (ERAS) protocols is crucial for successful liver surgery. The aim of this study was to assess the impact of minimally invasive liver surgery complexity on adherence after implementing an ERAS protocol. METHODS Between July 2018 and August 2021, a prospective observational study involving minimally invasive liver surgery patients was conducted. Perioperative treatment followed ERAS guidelines and was recorded in the ERAS interactive audit system. Kruskal-Wallis and ANOVA tests were used for analysis, and pairwise comparisons utilized Wilcoxon rank sum and Welch's t-tests, adjusted using Bonferroni correction. RESULTS A total of 243 patients were enrolled and categorized into four groups based on the Iwate criteria: low (n = 17), intermediate (n = 81), advanced (n = 74) and expert difficulty (n = 71). Complexity correlated with increased overall and major morbidity rate, as well as longer length of stay (all P < 0.001; standardized mean difference = 0.036, 0.451, 0.543 respectively). Adherence to ERAS measures decreased with higher complexity (P < 0.001). Overall adherence was 65.4%. Medical staff-centred adherence was 79.9%, while patient-centred adherence was 38.9% (P < 0.001). Complexity significantly affected patient-centred adherence (P < 0.001; standardized mean difference (SMD) = 0.420), but not medical staff-centred adherence (P = 0.098; SMD = 0.315). Postoperative phase adherence showed major differences among complexity groups (P < 0.001, SMD = 0.376), with mobilization measures adhered to less in higher complexity cases. CONCLUSION The complexity of minimally invasive liver surgery procedures impacts ERAS protocol adherence for each patient. This can be addressed using complexity-adjusted cut-offs and 'gradual adherence' based on the relative proportion of cut-off values achieved.
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Affiliation(s)
- Paul M Dahlke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Christian Benzing
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Can Kamali
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
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