[Patient evaluation of postoperative recovery. An evaluation of the QoR scores in 577 patients]

Open versus robotic-assisted partial nephrectomy in patients with intermediate/high-complexity kidney tumours: final results of the randomised, controlled, open-label, multicentre trial OpeRa

BACKGROUND

The prospective, randomised, open-label, multicentre OpeRa trial (NCT03849820) aimed to determine whether robotic-assisted partial nephrectomy (RAPN) is superior to open partial nephrectomy (OPN) in reducing 30-day postoperative complications during the treatment of intermediate/high-complexity renal tumours.

PATIENTS AND METHODS

Eligible patients aged ≥18 years had a renal tumour suitable for OPN or RAPN, a RENAL score ≥7, and an eGFR ≥50ml/min/1.73m2. Patients were randomised from 15-Mar-2019 to 23-Nov-2021 in 12 German hospitals and assigned (1:1) to undergo RAPN or OPN. Primary endpoint was the 30-day postoperative complication rate (Clavien-Dindo I-V) in the modified intention-to-treat (mITT) population. We aimed to recruit 606 patients to detect ≥10% reduction in the primary endpoint for RAPN vs. OPN.

RESULTS

240 patients were randomised to RAPN (n=123) or OPN (n=117). Enrolment was stopped prematurely due to slow recruitment. After patient withdrawal post-randomisation, 117 patients underwent RAPN and 90 OPN. The primary endpoint was assessable in 112 and 89 patients, respectively: The 30-day complication rate did not differ between groups: RAPN 41/112 (37%) vs. OPN 41/89 (46%) (one-sided: P=0.088). The difference of -9.5% (95% CI -23.1-4.2) numerically favoured RAPN. The most frequent high-grade complications (Clavien-Dindo III-IV) to postoperative day 30 (POD30) were urine leakage (RAPN 4/112 [4%] vs. OPN 2/89 [2%]) and postoperative bleeding (2/117 [2%] vs. 1/89 [1%]). Compared to OPN, RAPN patients had longer operative and warm ischaemia times, shorter hospital stay, and reported better recovery, less opioid use, less pain, and improved quality of life up to POD30.

CONCLUSIONS

There was no statistically significant difference in the 30-day complication rate between RAPN and OPN in this underpowered trial. Few high-grade complications occurred over the whole cohort with intermediate/high-complexity tumours. Despite less intense pain management, patients undergoing RAPN reported less pain and better quality of life up to POD30.

[Remimazolam-Update on basic pharmacologic principles and clinical potential]

In recent years the still relatively new short-acting benzodiazepine remimazolam has been approved and clinically implemented in several countries and regions. Remimazolam is also now approved in the EU and the market launch in Germany is expected in the not too distant future. This is therefore a good point in time to summarize the current evidence for various areas of application, including general anesthesia, sedation and intensive care medicine as well as different dosing schemes.

Goal-directed Perioperative Albumin Substitution Versus Standard of Care to Reduce Postoperative Complications: A Randomized Clinical Trial (SuperAdd Trial)

OBJECTIVE

To investigate whether goal-directed albumin substitution during surgery and postanesthesia care to maintain a serum albumin concentration >30 g/L can reduce postoperative complications.

BACKGROUND

Hypoalbuminemia is associated with numerous postoperative complications. Since albumin has important physiological functions, substitution of patients with hypoalbuminemia is worth considering.

METHODS

We conducted a single-center, randomized, controlled, outcome assessor-blinded clinical trial in adult patients, American Society of Anesthesiologists physical status classification 3 to 4 or undergoing high-risk surgery. Patients, whose serum albumin concentration dropped <30 g/L were randomly assigned to goal-directed albumin substitution maintaining serum concentration >30 g/L or to standard care until discharge from the postanesthesia intermediate care unit. Standard of care allowed albumin substitution in hemodynamic instable patients with serum concentration <20 g/L, only. Primary outcome was the incidence of postoperative complications ≥2 according to the Clavien-Dindo Classification in at least 1 of 9 domains (pulmonary, infectious, cardiovascular, neurological, renal, gastrointestinal, wound, pain, and hematological) until postoperative day 15.

RESULTS

Of 2509 included patients, 600 (23.9%) developed serum albumin concentrations <30 g/L. Human albumin 60 g (40-80 g) was substituted to 299 (99.7%) patients in the intervention group and to 54 (18.0%) in the standard care group. At least 1 postoperative complication classified as Clavien-Dindo Classification ≥2 occurred in 254 of 300 patients (84.7%) in the intervention group and in 262 of 300 (87.3%) in the standard treatment group (risk difference -2.7%, 95% CI, -8.3% to 2.9%).

CONCLUSION

Maintaining serum albumin concentration of >30 g/L perioperatively cannot generally be recommended in high-risk noncardiac surgery patients.

Analyzing robotic surgery impact on recovery quality & emotions

Background

The objective of this study is to investigate the postoperative recovery quality and emotional status of patients with non-small cell lung cancer (NSCLC) who underwent robot-assisted and video-assisted thoracoscopic surgery using the 15-item Quality of Recovery (QoR-15) scale and to analyze the correlation.

Methods

We collected clinical data from 320 patients with NSCLC who underwent lobectomy using either robot-assisted thoracoscopic surgery (RATS) or video-assisted thoracoscopic surgery (VATS) at our center from January 2021 to December 2022. We compared perioperative parameters and followed up after the operation using the QoR-15 scale to objectively assess the quality of postoperative recovery and physical and emotional status.

Results

Apart from a notable distinction in anesthesia time, no significant differences were observed in other general data. Notably, the overall recovery rate for patients in the RATS group surpassed that of the VATS group (P < 0.05). Specifically, the recovery rates in the RATS group were significantly superior to those in the VATS group across nociceptive factors, emotional factors, activities of daily living, physiological factors, and cognitive ability (P < 0.05). Spearman correlation analysis between surgical methods and various indicators of the QoR-15 scale showed significant correlations between surgical methods (P < 0.05).

Conclusion

The QoR-15 scale is a valuable tool for assessing the postoperative recovery quality in lung cancer patients. The RATS plays a significant role in promoting the swift postoperative recovery of patients and demonstrates excellent efficacy, safety, and reliability.

Prevention of peri-interventional hypothermia during endoscopic retrograde cholangiopancreatography using a forced-air heating system

Background and study aims Perioperative hypothermia is associated with significant complications and can be prevented with forced-air heating systems (FAHS). Whether hypothermia occurs during prolonged endoscopic sedation is unclear and prevention measures are not addressed in endoscopic sedation guidelines. We hypothesized that hypothermia also occurs in a significant proportion of patients undergoing endoscopic interventions associated with longer sedation times such as endoscopic retrograde cholangiopancreaticography (ERCP), and that FAHS may prevent it. Patients and methods In this observational study, each patient received two consecutive ERCPs, the first ERCP following current standard of care without FAHS (SOC group) and a consecutive ERCP with FAHS (FAHS group). The primary endpoint was maximum body temperature difference during sedation. Results Twenty-four patients were included. Median (interquartile range) maximum body temperature difference was -0.9°C (-1.2; -0.4) in the SOC and -0.1°C (-0.2; 0) in the FAHS group ( P < 0.001). Median body temperature was lower in the SOC compared with the FAHS group after 20, 30, 40, and 50 minutes of sedation. A reduction in body temperature of > 1°C ( P < 0.001) and a reduction below 36°C ( P = 0.01) occurred more often in the SOC than in the FAHS group. FAHS was independently associated with reduced risk of hypothermia ( P = 0.006). More patients experienced freezing in the SOC group ( P = 0.004). Hemodynmaic and respiratory stability were comparable in both groups. Conclusions Hypothermia occurred in the majority of patients undergoing prolonged endoscopic sedation without active temperature control. FAHS was associated with higher temperature stability during sedation and better patient comfort.

Evaluation of the impact of an enhanced recovery after surgery (ERAS) programme on the quality of recovery in patients undergoing a scheduled hysterectomy: a prospective single-centre before-after study protocol (RAACHYS study)

INTRODUCTION

The enhanced recovery after surgery (ERAS) programmes following hysterectomies have been studied since 2010, and their positive effects on clinical or economic criteria are now well established. However, the benefits on health outcomes, especially rapid recovery after surgery from patients' perspective is lacking in literature, leading to develop scores supporting person-centred and value-based care such as patient-reported outcome measures. The aim of this study is to assess the impact of an ERAS programme on patients' well-being after undergoing hysterectomy.

METHODS AND ANALYSIS

This is an observational, prospective single-centre before-after clinical trial. 148 patients are recruited and allocated into two groups, before and after ERAS programme implementation, respectively. The ERAS programme consists in optimising factors dealing with early rehabilitation, such as preoperative patient education, multimodal pain management, early postoperative fluid taken and mobilisation. A self-questionnaire quality of recovery-15 (QoR-15) on the preoperative day 1 (D-1), postoperative day 0 evening (D0) and the postoperative day 1 (D+1) is completed by patients. Patients scheduled to undergo hysterectomy, aged 18 years and above, whose physical status are classified as American Society of Anesthesiologists score 1-3 and who are able to return home after being discharged from hospital and contact their physician or the medical department if necessary are recruited for this study. The total duration of inclusion is 36 months. The primary outcome is the difference in QoR-15 scores measured on D+1 which will be compared between the 'before' and the 'after' group, using multiple linear regression model.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethical Committee (Paris, France). Subjects are actually being recruited after giving their oral agreement or non-objection to participate in this clinical trial and following the oral and written information given by the anaesthesiologist practitioner.Trial registration number: ClinicalTrials.gov: NCT04268576 (Pre-result).

Investigation of the Quality of Recovery of Surgical Patients Based on the Chinese Version of the Quality of Recovery-15 Survey, a Cross-Sectional Study

PURPOSE

The quality of recovery (QoR) is an important indicator of a patient's health status in the early postoperative period. Despite its importance, the QoR from the patient's perspective is often neglected in clinical practice. This study was performed to survey and determine the QoR of surgical patients from their own subjective perspective and to provide a reference for the targeted postoperative care of surgical patients in the future.

DESIGN

A descriptive and cross-sectional study.

METHODS

The Chinese version of the Quality of Recovery-15 (QoR-15) scale was used to survey the QoR of 503 surgical patients in 20 surgical wards from 17 surgical departments of a large tertiary hospital in Sichuan Province, China. A questionnaire survey was administered to each patient before and after the operation, and the scores were compared.

FINDINGS

There were no significant differences in "feeling worried or anxious" and "feeling sad or depressed" between the preoperative and postoperative periods (P > 0.05). The postoperative scores for the other items were significantly lower than the preoperative scores. The total postoperative QoR-15 score was significantly lower than the total preoperative score (P < 0.001).

CONCLUSIONS

The QoR-15 scores of surgical patients were lower after the surgery than before, and patients still needed care after discharge. Therefore, due to the gradual shortening of the length of stay (LOS) of surgical patients, it is necessary for hospitals to construct a complete surgical patient transitional care process to meet the needs of patients after discharge and promote patient rehabilitation.

Transversus abdominis Plane Block for Improved Early Postoperative Pain Management after Periacetabular Osteotomy: A Randomized Clinical Trial

Background: Patients undergoing periacetabular osteotomy (PAO) may experience significant postoperative pain due to the extensive approach and multiple osteotomies. The aim of this study was to assess the efficacy of the transversus abdominis plane (TAP) block on reducing opioid consumption and improving clinical outcome in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial in 42 consecutive patients undergoing a PAO for symptomatic developmental dysplasia of the hip (DDH). The study group received an ultrasound-guided TAP block with 20 mL of 0.75% ropivacaine prior to surgery. The control group did not receive a TAP block. All patients received a multimodal analgesia with nonsteroidal anti-inflammatory drugs (NSAID) (etoricoxib and metamizole) and an intravenous patient-controlled analgesia (PCA) with piritramide (1.5 mg bolus, 10 min lockout-time). The primary endpoint was opioid consumption within 48 h after surgery. Secondary endpoints were pain scores, assessment of postoperative nausea and vomiting (PONV), measurement of the quality of recovery using patient-reported outcome measure and length of hospital stay. Forty-one patients (n = 21 TAP block group, n = 20 control group) completed the study, per protocol. One patient was lost to follow-up. Thirty-three were women (88.5%) and eight men (19.5%). The mean age at the time of surgery was 28 years (18-43, SD ± 7.4). All TAP blocks were performed by an experienced senior anaesthesiologist and all operations were performed by a single, high volume surgeon. Results: The opioid consumption in the TAP block group was significantly lower compared to the control group at 6 (3 mg ± 2.8 vs. 10.8 mg ± 5.6, p < 0.0001), 24 (18.4 ± 16.2 vs. 30.8 ± 16.4, p = 0.01) and 48 h (29.1 mg ± 30.7 vs. 54.7 ± 29.6, p = 0.04) after surgery. Pain scores were significantly reduced in the TAP block group at 24 h after surgery. There were no other differences in secondary outcome parameters. No perioperative complication occurred in either group. Conclusion: Ultrasound-guided TAP block significantly reduces the perioperative opioid consumption in patients undergoing PAO.

[Videoassisted Thoracoscopy with Preserved Spontaneous Breathing - an Anaesthesiological Perspective]

INTRODUCTION

Video-assisted thoracoscopic procedures with preserved spontaneous breathing (NI-VATS = conscious video-assisted thoracic surgery) have enjoyed a revival in recent years. However, there have been few reports on proper patient selection, as well as surgical or anaesthesiologic management for these procedures in Germany. Therefore, we present our experience with NI-VATS procedures in the form of a case study and discuss the results with a current survey and the current literature.

METHOD

Retrospective evaluation of all NI-VATS procedures at our local institution.

RESULTS

From June 2018 to January 2020 n = 17 (9 male and 8 female) patients underwent NI-VATS at our institution. Median age of patients was 68 [61 - 79] years. Fourteen patients suffered from progressive cancer as the underlying disease, leading to thoracic surgery. All patients had a number of comorbidities and were classified according to the ASA categories III (n = 9) or IV (n = 8). Surgical procedures were of short duration (in median 18 [15 - 27] min) and included 82% pleural procedures (pleurectomy, decortication or insertion of pleural drainage). All patients tolerated the surgical procedures under local anaesthesia and conscious sedation very well. Eleven patients could therefore be transferred to the normal ward after surgery, while the remaining patients underwent prolonged and intensified postoperative monitoring. Five of the 17 patients died within the hospital, in median 8 [3.0 - 33.5] days after surgery, in context of the underlying disease. None of the deaths could be associated with the surgical procedures.

DISCUSSION

In a well selected patient cohort and with our local experience, NI-VATS is a safe and practicable alternative to standard thoracotomy in general anaesthesia and one-lung ventilation. In our local institution, multimorbid patients with interventions of short duration and reasonable extent underwent successful NI-VATS and emerged as good candidates for this procedure. Careful patient selection and knowledge of the procedure and its side effects present important milestones for successful NI-VATS.

Substitution of perioperative albumin deficiency disorders (SuperAdd) in adults undergoing vascular, abdominal, trauma, or orthopedic surgery: protocol for a randomized controlled trial

Background

Hypalbuminemia is associated with numerous postoperative complications, so a perioperative albumin substitution is often considered. The objective of SuperAdd is to investigate whether substitution of human albumin, aiming to maintain a serum concentration > 30 g/l, can reduce postoperative complications in normovolemic surgical patients in comparison with standard care.

Methods/design

SuperAdd is a single-center, prospective, randomized, outcome-assessor blinded, patient blinded controlled trial. The primary outcome is the frequency of postoperative complications identified using the Postoperative Morbidity Survey graded ≥ 2 according to the Clavien-Dindo Score. Adult patients at risk to develop hypalbuminemia, i.e., ASA III or IV or high-risk surgery, are recruited after written informed consent was obtained. The albumin concentration is assessed before the induction of anesthesia and every 3 h until admission to the postanesthesia care unit. If albumin concentrations drop below 30 g/l, patients are randomly allocated to the control or the treatment group. The study intervention is a goal-directed human albumin substitution aimed at a concentration > 30 g/l during surgery and postanesthesia care unit stay. The patients in the control group are treated according to standard clinical care. Postoperative visits are to be performed on days 1, 3, 5, 8, and 15, as well as by telephone 6 months after surgery.

Discussion

SuperAdd is the first clinical trial in a surgical population investigating the effect of a goal-directed albumin substitution aiming at a serum level > 30 g/l. The nonrestrictive selection of patients guarantees that the patients without albumin screening will most likely not develop hypalbuminemia, thus ensuring generalizability of the study results.

Trial registration

EudraCT 2016-001313-24. Registered on 5 September 2016. Clinical Trials NCT03167645. Registered on 18 October 2016 and has the Universal Trial Number (UTN) U1111-1181-2625.

Effects of epidural combined with general anesthesia versus general anesthesia on quality of recovery of elderly patients undergoing laparoscopic radical resection of colorectal cancer: A prospective randomized trial

STUDY OBJECTIVES

The aim of the present study was to assess the quality of recovery from anesthesia on patients subjected to laparoscopic radical resection of colorectal cancer under epidural block combined with general anesthesia or general anesthesia by means of Quality of Recovery-15 (QoR-15) questionnaire.

DESIGN

Prospective randomized trial.

SETTING

The setting is at an operating room, a post-anesthesia care unit, and a hospital ward.

PATIENTS

Seventy patients, aging from 65 to 79 years with an American Society of Anesthesiologists physical status II or III, were scheduled to undergo laparoscopic radical resection of colorectal cancer.

INTERVENTIONS

Epidural block combined with general anesthesia or general anesthesia.

MEASUREMENTS

The QoR-15 was administered by an investigator blind to group allocation before surgery (T₀), at 24 and 72h after surgery (T₁ and T₂), and on postoperative day 7 (T₃). The quality of recovery, as assessed by the score on the QoR-15, was compared between the groups. Besides, the consumption of anesthetics, respiratory recovery time, response time, extubation time, flatus time, the incidence of nausea or vomiting, the consumption of antiemetic and analgesic agents, and the duration of the hospital stay were also recorded.

MAIN RESULTS

The QoR-15 scores at T₁ and T₂ were significantly higher in the E + G group compared with the G group (P < 0.05). Among the five dimensions of the QoR-15, physiological comfort, physiological independence, pain, and emotional dimension were significantly better at T₁ in the E + G group, and physiological comfort and pain were significantly better at T₂ in the E + G group.

CONCLUSION

This study demonstrates that epidural block combined with general anesthesia can improve the early recovery of elderly patients after laparoscopic radical resection of colorectal cancer from the perspective of patients.

Self-Reported, Structured Measures of Recovery to Detect Postoperative Morbidity

Previous studies have focused on postoperative anaesthetic visit as a tool for measuring postoperative recovery or patient's satisfaction. Whether it could also improve timely recognition of complications has not been studied yet. Aim of our study was to assess pathological findings in physical examination requiring further intervention during postoperative visit and to explore whether a self-administered version of the Quality of Recovery (QoR)-9 score, compared to a detailed medical history, can act as a screening tool for identification of patients who show a low risk to develop postoperative complications. This observational study included 918 patients recovering from various types of non-cardiac surgery and anaesthesia. The postoperative visit implied three steps: measuring the QoR-9 score, a structured medical history and a physical examination. QoR-9-score showed a comparable negative predictive value (0.93 vs. 0.92) and a higher sensitivity of finding at least one pathological examination than a detailed medical history (0.92 vs. 0.81 respectively). At least one postoperative pathological examination finding was observed in 23.7% of the patients. Our approach presents a strategy on screening postoperative patients in order to identify patients whose examination and consequent treatment should be intensified. In further studies the question could be addressed whether the postoperative visit may help to reduce complications and mortality after surgery.

Randomised clinical trial of pilonidal sinus operations performed in the prone position under spinal anaesthesia with hyperbaric bupivacaine 0.5 % versus total intravenous anaesthesia

PURPOSE

The aim of this randomised clinical trial was to determine whether spinal anaesthesia (SPA) is superior to total intravenous anaesthesia (TIVA) in patients undergoing pilonidal sinus (PS) operations in the prone position.

METHODS

After approval of the local ethics committee, suitable patients aged 19-49 years were randomised to SPA (7.5 mg hyperbaric bupivacaine) or TIVA (Propofol and Fentanyl). Cumulative consumption of analgesics, postoperative recovery, complications and patient satisfaction were evaluated.

RESULTS

A total of 50 patients were randomised within a 24-month period. Median monitoring time in the recovery room was 0 (0-11) min for SPA versus 40 (5-145) min for TIVA (p < 0.0001). Patients in the SPA group were able to drink (40.5 (0-327) min versus TIVA 171 (72-280) min, p < 0.0001) and eat (55 (0-333) min versus TIVA 220 (85-358), p < 0.0001) earlier. More patients with a TIVA needed analgesics in the recovery room (SPA n = 0 versus TIVA n = 6, p = 0.0023) and suffered more frequently from a sore throat (SPA n = 0 versus TIVA n = 11, p = 0.0001). Two patients with a TIVA suffered from nausea and vomiting. Patients of both groups were equally satisfied with the anaesthesia technique offered.

CONCLUSIONS

SPA with 7.5 mg hyperbaric bupivacaine is superior to TIVA in patients undergoing PS operations in the prone position in terms of analgesia consumption in the recovery room, recovery times and postoperative complications.

Patient acceptance of awake craniotomy

OBJECTIVES

The aim of this study was to objectively assess the patients' acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas.

PATIENTS AND METHODS

Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data.

RESULTS

The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p=0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales "postoperative pain" (p=0.02) and "physical disorders" (p=0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients' acceptance for AC.

CONCLUSION

Previous studies have shown good patients' acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences.

[The Anaesthesiological Questionnaire for patients in cardiac anaesthesia. Results of a multicenter survey by the scientific working group for cardiac anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine]

OBJECTIVE

The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire was adapted for use in cardiac anaesthesia (ANP-KA). The study was conducted to show the value of ANP-KA as a practicable means of assessing the patient's state after cardiac anaesthesia and for its use in quality assurance.

METHODS

A total of 1,688 patients from 19 clinics were included who had exclusively received heart valve surgery, CABG surgery or both operations. They completed the ANP-KA between days 1 and 8 postoperatively.

RESULTS

The ANP-KA was completed by 79.1% of the patients without any assistance. The highest incidence rates were reported for a dry mouth/thirst (85.1%) and for pain in the area of surgery (60.2%). Plausible and significant differences in patients' symptoms between the grading for the immediate postoperative period and the current state at filling in the questionnaire were found. Women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with anaesthesiological care and convalescence. More complaints were reported after heart valve surgery than after CABG and satisfaction with convalescence was significantly lower after heart valve surgery. The clinics differed with respect to the reported somatic complaints and satisfaction scales.

CONCLUSION

The results demonstrate the practicability and validity of the ANP-KA for the assessment of postoperative complaints and patient satisfaction after cardiac surgery.