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Geroin C, Weindelmayer J, Camozzi S, Leone B, Turolo C, Hetoja S, Bencivenga M, Sacco M, De Pasqual CA, Mattioni E, de Manzoni G, Giacopuzzi S. Clinical predictors of postoperative complications in the context of enhanced recovery (ERAS) in patients with esophageal and gastric cancer. Updates Surg 2024:10.1007/s13304-023-01739-6. [PMID: 38358642 DOI: 10.1007/s13304-023-01739-6] [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: 06/02/2023] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Abstract
The overall frequency of postoperative complications in patients with esophageal and gastric cancer diverges between studies. We evaluated the frequency and assessed the relationship between complications and demographic and clinical features. For this observational study, data were extracted from the ERAS Registry managed by the University of Verona, Italy. Patients were evaluated and compared for postoperative complications according to the consensus-based classification and the Clavien-Dindo scale. The study population was 877 patients: 346 (39.5%) with esophageal and 531 (60.5%) with gastric cancer; 492 (56.2%) reported one or more postoperative complications, 213 (61.6%) of those with esophageal and 279 (52.5%) of those with gastric cancer. When stratified by consensus-based classification, patients with esophageal cancer reported general postoperative complications more frequently (p < 0.001) than those with gastric cancer, but there was no difference in postoperative surgical complications between the two groups. Multiple logistic regression models revealed an association between postoperative complications and the Charlson Comorbidity Index (adjusted odds ratio [OR] 1.22; 95% confidence interval [CI] 1.08-1.36), operation time (adjusted OR, 1.08; 95% CI 1.00-1.15), and days to solid diet intake (adjusted OR, 1.39; 95% CI 1.20-1.59). Complications in patients with esophageal and gastric cancer are frequent, even in those treated according to ERAS principles, and are often associated with comorbidities, longer operative time, and longer time to solid diet intake.
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Affiliation(s)
- Christian Geroin
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy.
| | - Jacopo Weindelmayer
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Serena Camozzi
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Barbara Leone
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Cecilia Turolo
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Selma Hetoja
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Maria Bencivenga
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Michele Sacco
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | | | - Eugenia Mattioni
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy
| | - Simone Giacopuzzi
- General and Upper G.I. Surgery Division, University of Verona, Borgo Trento, Verona, Italy.
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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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Dyas AR, Kelleher AD, Cumbler EU, Barker AR, McCabe KO, Bata KE, Abrams BA, Randhawa SK, Mitchell JD, Meguid RA. Quality Review Committee Audit Improves Thoracic Enhanced Recovery After Surgery Protocol Compliance. J Surg Res 2024; 293:144-151. [PMID: 37774591 DOI: 10.1016/j.jss.2023.08.022] [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: 03/07/2023] [Revised: 08/01/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Compliance with thoracic Enhanced Recovery After Surgery (ERAS) protocols is critical to achieving their maximum benefits. We sought to examine utilization of quality review meetings as a method to improve protocol compliance through identification and resolution of barriers with compliance. METHODS A multidisciplinary committee implemented a thoracic ERAS protocol for anatomic lung resections across five hospitals within our health system. Compliance data at one institution were tracked for 4 mo after initiation of the ERAS protocol; a quality review meeting was held at one hospital, and two additional months of compliance data were recorded. Outcomes of interest were compliance changes to five protocol elements. Pathway elements deferred due to "mindful deviation" were excluded. Chi-square and Fisher's exact tests were used to compare compliance differences. RESULTS We included 81 patients: 53 patients before the quality review meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall compliance improved from 53% before to 84% after the quality review meeting. Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in postanesthesia care unit, liberal chest tube removal, and postoperative multimodal pain regimen use improved after the quality review meeting (P values <0.05). Use of preoperative pain bundles was not significantly different (87% versus 96%, P = 0.25). CONCLUSIONS Conducting a quality review meeting significantly improved ERAS protocol element use at our intervention healthcare region. This methodology should be considered at other institutions implementing surgical protocols.
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Affiliation(s)
- Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, University of Colorado Hospital, Aurora, Colorado.
| | - Alyson D Kelleher
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Ethan U Cumbler
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado; Department of Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Alison R Barker
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Katherine O McCabe
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Kyle E Bata
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado Hospital, Aurora, Colorado
| | - Simran K Randhawa
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - John D Mitchell
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, University of Colorado Hospital, Aurora, Colorado
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Realis Luc M, de Pascale S, Ascari F, Bonomi AM, Bertani E, Cella CA, Gervaso L, Fumagalli Romario U. Textbook outcome as indicator of surgical quality in a single Western center: results from 300 consecutive gastrectomies. Updates Surg 2023:10.1007/s13304-023-01727-w. [PMID: 38145422 DOI: 10.1007/s13304-023-01727-w] [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: 09/10/2023] [Accepted: 12/01/2023] [Indexed: 12/26/2023]
Abstract
Textbook outcome (TO) has been proposed as a tool to evaluate surgical quality. Textbook oncological outcome (TOO) adds chemotherapeutic compliance to TO. This study was conducted to analyze the TO and TOO of patients with gastric adenocarcinoma who underwent surgery at our center. Data from a prospective database of patients operated on for gastric adenocarcinoma between September 2018 and September 2022 were analyzed. Postoperative management followed Enhanced Recovery After Surgery guidelines. The Dutch Upper Gastrointestinal Cancer Audit group defined TO as a multidimensional measure (10 items). TOO also considers guideline-accordant chemotherapeutic compliance. Three hundred patients underwent surgery during the study period (167 men, 133 women). One hundred seventy-six (58.7%) reached TO. Achieving TO was influenced by patients' comorbidities, calculated via the Charlson Comorbidity Score (3 vs. 4; p = 0.002) and surgery type (subtotal gastrectomy; p < 0.001), but not by the American Society of Anesthesiologists (ASA) score (p = 0.057) or surgical approach (laparoscopic vs. open; p = 0.208). The analysis of TOO included 213 patients. Of these, 71 (33%) underwent complete adequate systemic treatment. Compared with the non-TOO group, patients who achieved TOO had a lower median age (64 vs. 73 years; p < 0.001) and lower ASA score (p < 0.001) and more frequently underwent preoperative chemotherapy (p < 0.001). Our results represent the experience of a single team at a high-volume Western institute. Patients' comorbidities and surgery type influenced whether TO was achieved. Conversely, younger age, lower ASA score and preoperative chemotherapy were associated with TOO.
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Affiliation(s)
- Marco Realis Luc
- Digestive Surgery, European Institute of Oncology, IRCCS, Milan, Italy.
- University of Milan, Milan, Italy.
| | | | - Filippo Ascari
- Digestive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Alessandro Michele Bonomi
- Digestive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
- University of Milan, Milan, Italy
| | - Emilio Bertani
- Digestive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Alessandra Cella
- Division of Gastrointestinal and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Lorenzo Gervaso
- Division of Gastrointestinal and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
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Lorenzon L, Caccialanza R, Casalone V, Santoro G, Delrio P, Izzo F, Tonello M, Mele MC, Pozzo C, Pedrazzoli P, Pietrabissa A, Fenu P, Mellano A, Fenocchio E, Avallone A, Bergamo F, Nardi MT, Persiani R, Biondi A, Tirelli F, Agnes A, Ferraris R, Quarà V, Milanesio M, Ribero D, Rinaldi M, D'Elia P, Rho M, Cenzi C, D'Ugo D. The impact of preoperative nutritional screening, ERAS protocol, and mini-invasive surgery in surgical oncology: A multi-institutional SEM analysis of patients with digestive cancer. Front Nutr 2023; 10:1041153. [PMID: 37006925 PMCID: PMC10063158 DOI: 10.3389/fnut.2023.1041153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundMini-invasive surgery (MIS), ERAS, and preoperative nutritional screening are currently used to reduce complications and the length of hospital stay (LOS); however, inter-variable correlations have seldom been explored. This research aimed to define inter-variable correlations in a large series of patients with gastrointestinal cancer and their impact on outcomes.MethodsPatients with consecutive cancer who underwent radical gastrointestinal surgery between 2019 and 2020 were analyzed. Age, BMI, comorbidities, ERAS, nutritional screening, and MIS were evaluated to determine their impact on 30-day complications and LOS. Inter-variable correlations were measured, and a latent variable was computed to define the patients' performance status using nutritional screening and comorbidity. Analyses were conducted using structural equation modeling (SEM).ResultsOf the 1,968 eligible patients, 1,648 were analyzed. Univariable analyses documented the benefit of nutritional screening for LOS and MIS and ERAS (≥7 items) for LOS and complications; conversely, being male and comorbidities correlated with complications, while increased age and BMI correlated with worse outcomes. SEM analysis revealed that (a) the latent variable is explained by the use of nutritional screening (p0·004); (b) the variables were correlated (age–comorbidity, ERAS–MIS, and ERAS–nutritional screening, p < 0·001); and (c) their impact on the outcomes was based on direct effects (complications: sex, p0·001), indirect effects (LOS: MIS-ERAS-nutritional screening, p < 0·001; complications: MIS-ERAS, p0·001), and regression-based effects (LOS: ERAS, MIS, p < 0·001, nutritional screening, p0·021; complications: ERAS, MIS, p < 0·001, sex, p0·001). Finally, LOS and complications were correlated (p < 0·001).ConclusionEnhanced recovery after surgery (ERAS), MIS, and nutritional screening are beneficial in surgical oncology; however, the inter-variable correlation is reliable, underlying the importance of the multidisciplinary approach.
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Affiliation(s)
- Laura Lorenzon
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
- *Correspondence: Laura Lorenzon
| | | | | | - Gloria Santoro
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Paolo Delrio
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Francesco Izzo
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Marco Tonello
- Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Maria Cristina Mele
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Carmelo Pozzo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | | | - Piero Fenu
- Candiolo Cancer Institute–IRCCS, Turin, Italy
| | | | | | - Antonio Avallone
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | | | | | - Roberto Persiani
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alberto Biondi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Flavio Tirelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Annamaria Agnes
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | | | | | | | | | | | - Maurizio Rho
- Istituto Nazionale per lo Studio e la Cura dei Tumori Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Carola Cenzi
- Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Domenico D'Ugo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs. J Patient Saf 2023; 19:86-92. [PMID: 36696585 DOI: 10.1097/pts.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio. METHODS Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics. RESULTS The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633). CONCLUSIONS A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run.
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State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience. Updates Surg 2023; 75:373-382. [PMID: 35727482 DOI: 10.1007/s13304-022-01311-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/26/2022] [Indexed: 01/24/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.
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Charlene Kwa XW, Mathew C, Tan TK. ERAS journey: an abridged account for the busy practitioner. Singapore Med J 2023; 0:367495. [PMID: 36695279 DOI: 10.4103/singaporemedj.smj-2020-513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
| | | | - Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Romario UF, Ascari F, De Pascale S, Bencini L, Cocozza E, Cotsoglou C, Degiuli M, Palma G, Ferrari G, Lucianetti A, Marchesi F, Merigliano S, Millo P, Navarra G, Petri R, Portolani N, Puzziello A, Rosati R, Weindelmayer J, Ercolani G, De Palma G. Implementation of the ERAS program in gastric surgery: a nationwide survey in Italy. Updates Surg 2023; 75:141-148. [PMID: 36307670 PMCID: PMC9616397 DOI: 10.1007/s13304-022-01400-8] [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: 05/19/2022] [Accepted: 10/04/2022] [Indexed: 01/14/2023]
Abstract
Enhanced recovery after surgery (ERAS) programs have been developed by combining several evidence-based techniques for perioperative care, with the intention of reducing the stress response and organ dysfunction, thus allowing improved clinical results. ERAS programs have been widely adopted for colorectal surgery; however, their adoption for upper gastrointestinal surgery has been challenging even though good results have been reported in the literature. Our intent was to investigate the adoption of ERAS programs for resective gastric surgery in Italy. A survey was conducted among 20 departments of surgery belonging to the Italian Group for Research on Gastric Cancer (GC). Analysis of our survey showed that several evidence-based practices and many items of the ERAS guidelines for gastric surgery are not implemented in real practice in Italian centers dedicated to GC. This situation may be related to the hesitation of surgeons to introduce radical changes to the traditional postoperative management after gastrectomy. A multidisciplinary approach to the perioperative care of these patients is not routinely applied in many Italian centers. A strict collaboration of all clinicians involved in the perioperative care of patients undergoing gastrectomy for GC is key for the future implementation of ERAS in gastric surgery in our departments.
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Affiliation(s)
- Uberto Fumagalli Romario
- grid.15667.330000 0004 1757 0843Digestive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
| | - Filippo Ascari
- grid.15667.330000 0004 1757 0843Digestive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
| | - Stefano De Pascale
- grid.15667.330000 0004 1757 0843Digestive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
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Marano L, Marmorino F, Desideri I, Carbone L, Rizzo A, Salvestrini V, Roviello F, Cinieri S, Donato V, De Luca R. Clinical nutrition in surgical oncology: Young AIOM-AIRO-SICO multidisciplinary national survey on behalf of NutriOnc research group. Front Nutr 2023; 10:1045022. [PMID: 37125048 PMCID: PMC10140427 DOI: 10.3389/fnut.2023.1045022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/17/2023] [Indexed: 05/02/2023] Open
Abstract
Malnutrition is a common condition in cancer patients which is usually associated with functional limitations, as well as increased morbidity and mortality. Based on the support of the young sections of Italian Association of Medical Oncology (AIOM), Italian Association of Radiotherapy and Clinical Oncology (AIRO) and Italian Society of Surgical Oncology (SICO) merged into the NutriOnc Research Group, we performed a multidisciplinary national survey with the aim to define the awareness of nutritional issues among healthcare professionals delivering anticancer care. The questionnaire was organized in four sections, as follows: Knowledge and practices regarding Nutritional Management of cancer patients; Timing of screening and assessment of Nutritional Status; Nutritional Treatment and prescription criteria; Immunonutrition and educational topics. The modules focused on esophagogastric, hepato-bilio-pancreatic and colorectal malignancies. Overall, 215 physicians completed the survey. As regards the management of Nutritional Status of cancer patients, many responders adopted the ERAS program (49.3%), while a consistent number of professionals did not follow a specific validated nutritional care protocol (41.8%), mainly due to lack of educational courses (14.5%) and financial support (15.3%). Nearly all the included institutions had a multidisciplinary team (92%) to finalize the treatment decision-making. Cancer patients routinely underwent nutritional screening according to 57.2% of interviewed physicians. The timing of nutritional assessment was at diagnosis (37.8%), before surgery (25.9%), after surgery (16.7%), before radiochemotherapy (13.5%) and after radiochemotherapy (7%). Most of the responders reported that nutritional status was assessed throughout the duration of cancer treatments (55.6%). An important gap between current delivery and need of nutritional assessment persists. The development of specific and defined care protocols and the adherence to these tools may be the key to improving nutritional support management in clinical practice.
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Affiliation(s)
- Luigi Marano
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Federica Marmorino
- Unit of Oncology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- *Correspondence: Ludovico Carbone,
| | - Alessandro Rizzo
- Don Tonino Bello Oncology, IRCCS Istituto Tumori Giovanni Paolo II Bari, Bari, Italy
| | - Viola Salvestrini
- CyberKnife Center, Istituto Fiorentino di Cura ed Assistenza, Florence, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Saverio Cinieri
- Medical Oncology Division and Breast Unit, Antonio Perrino Hospital, Brindisi, Italy
| | - Vittorio Donato
- Department of Image Diagnostics, Ospedale San Camillo Forlanini, Rome, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
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Düzgün Ö, Özcan P, Özçelik MF. Did the ERAS Protocol Improve Our Results in Locally Advanced Gastric Cancer Surgery? J Pers Med 2022; 12:1549. [PMID: 36294688 PMCID: PMC9605348 DOI: 10.3390/jpm12101549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 08/10/2023] Open
Abstract
ERAS is a protocol consisting of multidisciplinary approaches, including patient education, fluid resuscitation, keeping patients' innormothermic state, early feeding, and mobilization. We aimed to present and compare the postoperative results of patients operated on due to locally advanced gastric cancer who received neoadjuvant therapy in two high-volume tertiary centers, and aimed to present that ERAS protocols can be applied with success without increasing the complication rate. This retrospective study consisted of two groups: a non-ERAS group and an ERAS group. The ERAS group consisted of 106 patients and the non-ERAS group consisted of 104 patients. The time to first flatus was shorter in the ERAS group compared with the non-ERAS group: 2.8 (1-5) and 3.5 (1-5, p = 0.008), respectively. The average stay at the hospital was 9 (7-22) days in thenon-ERAS group and 6.5 (5-14) days in the ERAS group. Readmission to the hospital within first 15 days after discharge was observed in one (%0.9) patient in the non-ERAS group and in four (%3.8) patients in the ERAS group. ERAS protocols contribute positively to the nutritional status of patients by reducing surgical stress and the rate of hospitalization, and reducing health costs. However, it appears to be associated with increased readmission rates.
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Affiliation(s)
- Özgül Düzgün
- Department of Surgical Oncology, İstanbul Umraniye Training and Research Hospital, University of Health Sciences, Istanbul 34766, Turkey
| | - Pırıltı Özcan
- Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul 34098, Turkey
| | - Mehmet Faik Özçelik
- Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul 34098, Turkey
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Grieco M, Delrio P, Lorenzon L, Agnes AL, Caccialanza R, Pedrazzoli P, Santoro G, Roviello F, Carlini M. Nutritional support in surgical oncology: A survey by SICO in collaboration with the Intersociety Italian Working Group for Nutritional Support in Cancer Patients. Surg Oncol 2022; 43:101788. [PMID: 35749913 DOI: 10.1016/j.suronc.2022.101788] [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: 04/11/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Nutritional support is a keystone component in perioperative care in patients undergoing oncological surgery with a direct impact on surgical outcomes. This study aimed to evaluate how nutritional support in the surgical setting is managed and applied in Italian hospitals. METHODS A national survey was designed by the Italian Society of Surgical Oncology (SICO) and disseminated in early 2021. The results were analyzed for the entire population and for comparing the following different subgroups: northern vs. southern regions; high-volume vs. low-volume centers; and junior vs. senior surgeons. RESULTS Out of the 141 responses collected from all Italian regions, 43.2% of the participants worked in a surgical unit where nutritional status evaluations and interventions were not routinely practiced, although the key features (nutritional counseling, oral supplementation, enteral and parenteral nutrition) were available in 77.3% of the hospitals. Among the participating centers, the ERAS protocol was systematically applied in only 29.5% of cases, and in 25.5% of cases, most of the items were followed, although not systematically. Among the surgeons who practiced in compliance with the ERAS pathways, almost half of the participants declared that the protocol was applied only for low-risk patients. No significant differences were documented when comparing Italian regions, high-volume vs. low-volume institutions or junior vs. senior participants. CONCLUSION Nutritional support in oncological surgery is frequently neglected in Italian hospitals, regardless of the geographic distribution and volumes of the institutions. A cultural change and an improvement in the availability of nutritional services are needed for widespread implementation.
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Affiliation(s)
- Michele Grieco
- General Surgery Unit, S. Eugenio Hospital, Rome, Italy. https://twitter.com/MicheleGriecoMD
| | - Paolo Delrio
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Laura Lorenzon
- General Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Amedea Luciana Agnes
- Endocrine Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Gloria Santoro
- General Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Franco Roviello
- Surgical Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Rosa F, Longo F, Pozzo C, Strippoli A, Quero G, Fiorillo C, Mele MC, Alfieri S. Enhanced recovery after surgery (ERAS) versus standard recovery for gastric cancer patients: The evidences and the issues. Surg Oncol 2022; 41:101727. [PMID: 35189515 DOI: 10.1016/j.suronc.2022.101727] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/25/2022] [Accepted: 02/13/2022] [Indexed: 12/24/2022]
Abstract
The significant advances that have been reached, in the last decades, in the treatment of gastric cancer, contributed to the concept of enhanced recovery after surgery (ERAS) with the aim to reduce the surgical stress, accelerate postoperative recovery, and reduce the length of hospital stay. The most important items included in the ERAS protocols are the pre-operative patient education, early mobilization and immediate oral intake from the first postoperative day. The aim of this narrative review is to focus the attention on the possible advantages of ERAS program on perioperative functional recovery outcomes after gastrectomy for gastric cancer.
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Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carmelo Pozzo
- Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonia Strippoli
- Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Cristina Mele
- Nutrition in Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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14
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Actual compliance rate of Enhanced Recovery After Surgery protocol in laparoscopic distal gastrectomy. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:184-190. [PMID: 35602855 PMCID: PMC8965987 DOI: 10.7602/jmis.2021.24.4.184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 11/23/2022]
Abstract
Purpose The Enhanced Recovery After Surgery (ERAS) protocol enhances recovery rate after laparoscopic distal gastrectomy (LDG). An ERAS protocol has been applied to most patients who underwent LDG at our center. In this study, we determined the actual compliance rate of the ERAS protocol and analyzed the risk factors for noncompliance. Methods Medical records of 1,013 patients who underwent LDG from March 2016 to December 2017 were reviewed retrospectively. The compliance group (A) included 327 patients who were discharged within four days postoperatively. The noncompliance group (B) comprised 686 patients who were not discharged within four days postoperatively. Results The compliance rate of the ERAS protocol was 32.3%. Potential compliance rate was 53.2%. Most common reasons for noncompliance were fever (n = 115) and ileus (n = 111). The 30-day emergency room visit rate was significantly lower in group A than that in group B (p = 0.006). Median age, American Society of Anesthesiologists (ASA) physical status classification, operation time, and pathologic stage were significantly higher in group B than those in group A (p < 0.001, p < 0.001, p = 0.005, and p < 0.001, respectively). Risk factors for noncompliance were ASA classification of ≥III (odds ratio [OR], 2.251; p = 0.007), age of ≥70 years (OR, 1.572; p = 0.004), operation time of ≥180 minutes (OR, 1.475; p = 0.003), and pathologic stage of ≥III (OR, 2.224; p < 0.001). Conclusion The current ERAS protocols should be applied to patients without risk factors.
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15
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Bae JH. Enhanced recovery after surgery: importance of compliance audits. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.12.820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The enhanced recovery after surgery (ERAS) protocol is associated with improved clinical outcomes. However, implementation of ERAS in clinical practice is difficult because it requires a multidisciplinary approach and complex standardization. Moreover, maintenance and auditing of ERAS protocols is another challenge.Current Concepts: The ERAS society provides guidelines for surgery in almost all areas, and each guideline consists of approximately 20 items. Audits are performed to determine whether the items are being applied appropriately in a compliant manner as well as monitor and improve ERAS protocols. Numerous studies have reported that even with the application of the same ERAS protocol, postoperative short-term outcomes such as reductions of hospital stay and postoperative complications were better in the high-compliance group than in the low-compliance group. In addition, some recent studies have reported that application of ERAS protocols with high compliance can improve the long-term survival outcomes in cancer patients. In this regard, ERAS has been hypothesized to improve long-term oncological outcomes by minimizing surgical stress and reducing the postoperative inflammatory response and damage to immune function.Discussion and Conclusion: In addition to the development of appropriate protocols, auditing of compliance is also an important part of ERAS implementation. High compliance may lead to improved clinical outcomes.
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16
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M.íximo MA, Santos D, F..lix-Oliveira A, Pereira M, Carmona C. Association between enhanced recovery after surgery protocol compliance and clinical complications: a cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:25-35. [PMID: 34627833 PMCID: PMC9801197 DOI: 10.1016/j.bjane.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/29/2021] [Accepted: 08/08/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocol is composed by evidence-based interventions that aim to improve recovery through a reduction in surgical stress response. Although ERAS protocols have been introduced across the globe, exhaustive implementation is not as common. We aimed to study the ERAS protocol compliance in colorectal surgery, assessing the relationship between compliance and postoperative complications. METHODS A single-center cohort study was conducted. All consecutive patients admitted to elective colorectal surgery were included. We assessed study endpoints according to ERAS protocol perioperative compliance score above 75%. Our primary endpoint was a composite of postoperative events, which includes in-hospital postoperative complications and need for reoperation after 30 days and need for readmission after discharge. Secondary endpoints were surgery-to-discharge time, postoperative use of only non-opioid adjuvants and the individual components of the primary endpoint. RESULTS A total of 224 colorectal patients were included. The primary endpoint occurred in 59.2% (n.á=.á58) of non-compliant patients comparing to 34.1% (n.á=.á43) in compliant patients. In univariate analysis, compliance to ERAS protocol had an inferior risk for the primary endpoint (p.á<.á0.001). In a logistic regression model, compliance was independently associated with a reduced risk for the primary endpoint with a odds-ratio of 0.42 (95% CI 0.23.Çô0.75, p.á=.á0.004). CONCLUSION Compliance with the ERAS protocol is associated with less complications, a reduced surgery-to-discharge time and use of only non-opioid adjuvants in the postoperative period. More studies are needed to target the most appropriate compliance goal.
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Affiliation(s)
- Maria Ana M.íximo
- Hospital Prof. Doutor Fernando Fonseca, E.P.E., Anesthesiology Department, Lisbon, Portugal,Corresponding author.
| | - Daniel Santos
- Hospital Prof. Doutor Fernando Fonseca, E.P.E., Anesthesiology Department, Lisbon, Portugal
| | - Afonso F..lix-Oliveira
- Centro Hospitalar Lisboa Ocidental, E.P.E., Hospital de Santa Cruz, Cardiology Department, Lisbon, Portugal,Centro Acad..mico de Medicina de Lisboa, Universidade de Lisboa, Faculdade de Medicina, Instituto de Farmacologia e Neuroci.¬ncias, Lisbon, Portugal
| | - Marta Pereira
- Champalimaud Centre for the Unknown - Champalimaud Clinical Centre Lisbon, Anesthesiology Department, Lisbon, Portugal
| | - Cristina Carmona
- Hospital Prof. Doutor Fernando Fonseca, E.P.E., Anesthesiology Department, Lisbon, Portugal
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17
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Martin L, Gillis C, Ljungqvist O. Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity? Curr Opin Clin Nutr Metab Care 2021; 24:453-463. [PMID: 34155154 DOI: 10.1097/mco.0000000000000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation. RECENT FINDINGS All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening. SUMMARY There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.
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Affiliation(s)
- Lisa Martin
- Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Québec, Canada
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
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18
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Koh FH, Chua JMW, Tan JLJ, Foo FJ, Tan WJ, Sivarajah SS, Ho LML, Teh BT, Chew MH. Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data. World J Gastrointest Surg 2021; 13:734-755. [PMID: 34512898 PMCID: PMC8394378 DOI: 10.4240/wjgs.v13.i8.734] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/08/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.
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Affiliation(s)
- Frederick H Koh
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Jason MW Chua
- Institute of Molecular and Cell Biology, Agency for Science Technology and Research, Singapore 138673, Singapore
| | - Joselyn LJ Tan
- Institute of Molecular and Cell Biology, Agency for Science Technology and Research, Singapore 138673, Singapore
| | - Fung-Joon Foo
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Winson J Tan
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | | | - Leonard Ming Li Ho
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Bin-Tean Teh
- Duke-NUS Graduate Medical School, National Cancer Centre Singapore, Singapore 169610, Singapore
| | - Min-Hoe Chew
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
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Willis MA, Schwenk W, Post S, Nothacker M, Follmann M, Vilz TO. [Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]. Zentralbl Chir 2021; 146:241-248. [PMID: 34154005 DOI: 10.1055/a-1481-9394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.
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Affiliation(s)
- Maria A Willis
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
| | | | - Stefan Post
- ehemals Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Monika Nothacker
- Philipps-Universität Marburg, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg, Deutschland
| | - Markus Follmann
- Office des Leitlinienprogrammes Onkologie, Deutsche Krebsgesellschaft e. V., Berlin, Deutschland
| | - Tim O Vilz
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland
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Panza J, Prescott L, Sorabella L, Dumas S, Helou C, Adam R. Compliance and outcomes after implementation of an enhanced recovery surgical protocol in older women undergoing pelvic reconstructive surgery. J Perioper Pract 2020; 30:352-359. [PMID: 32301385 DOI: 10.1177/1750458920907885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The aim of this study is to evaluate compliance and outcomes with implementation of an enhanced recovery surgical protocol in older women undergoing pelvic reconstructive surgery. This is a retrospective cohort study of women undergoing pelvic reconstructive surgery after implementation of the pathway over a 12-month period. Overall compliance was defined as a categorial variable requiring adherence to all of the selected bundle components in patients <65 years old compared to those ≥65. Intraoperative and 30-day postoperative complications were also compared and were reviewed by organ system, these were categorized using the Clavien-Dindo Classification system. There was no significant difference in overall compliance in patients <65 compared to ≥65. Factors that increased compliance in patients ≥65 include laparotomy, hysterectomy, hyperlipidaemia, time after implementation of the protocol and primary surgeon. There was an increase in compliance from 19% to 77% over the 12-month study period. Intra and postoperative complications were similar between the two groups. Enhanced recovery in older patients undergoing pelvic reconstructive surgery is feasible with similar rates of compliance and complications compared to younger patients. Compliance with the protocol increases as time after implementation of the protocol increases in all patients.
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Affiliation(s)
- Joseph Panza
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren Prescott
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan Dumas
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christine Helou
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rony Adam
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
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Lorenzon L, Brandl A, Guiral DC, Hoogwater F, Lundon D, Marano L, Montagna G, Polom K, Primavesi F, Schrage Y, Gonzalez-Moreno S, Kovacs T, D'Ugo D, Sandrucci S. Nutritional assessment in surgical oncology: An ESSO-EYSAC global survey. Eur J Surg Oncol 2020; 46:2074-2082. [PMID: 32938568 DOI: 10.1016/j.ejso.2020.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/21/2020] [Accepted: 08/28/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The majority of cancer patients report malnutrition, with a significant impact on patient's outcome. This study aimed to compare how nutritional assessment is conducted across different surgical oncology sub-specialties. METHODS Survey modules were designed for breast, hepato-pancreato-biliary (HPB), upper-gastrointestinal (UGI), sarcoma, peritoneal and surface malignancies (PSM) and colorectal cancer (CRC) surgeries to describe 4 domains: participants' setting, evaluation of clinical factors, use of screening tools and clinical practice. Results were compared among sub-specialties and according to human development index (HDI) in the largest cohorts. RESULTS Out of 457 answers from 377 global participants (62% European), 35.0% were from breast and 28.9% were from CRC surgeons. Although MDTs management is consistently reported (64-88%), the presence of a nutritionist/dietician ranges from 14.1% to 44.2%. Breast surgeons seldom evaluate albumin (25.6%) and weight loss (30.6%), opposite to HPB, PSM and UGI groups (>70%, p 0.044). Overall, responders declared that the use of screening tools is largely neglected, that nutritional status is often assessed by the surgeons and that nutrition is not consistently modified according to risk factors (range among groups respectively: 1.9%-25.6%, 33.1%-51.4%, 33.1%-60.5%). Less than 20% of breast surgeons assess patients before/after surgery, comparing to >60% of PSM surgeons. However, no statistical differences were documented comparing groups for the majority of the items of the 4 domains. Nutritional evaluation is more often conducted by breast surgeons in medium/low HDI countries comparing very high/high HDI (p 0.04). CONCLUSIONS Nutritional assessment is largely neglected. These results identify target-issues for the implementation of clinical practice.
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Affiliation(s)
- Laura Lorenzon
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy.
| | - Andreas Brandl
- Champalimaud Centre for the Unknown, Digestive Unit, Lisbon, Portugal
| | - Delia Cortes Guiral
- Universitary Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Frederik Hoogwater
- University Medical Center, Department of Surgery, Groningen, Netherlands
| | - Dara Lundon
- The Conway Institute, University College Dublin, Dublin, Ireland
| | - Luigi Marano
- University of Siena, Department of Medicine, Surgery, and Neurosciences, Siena, Italy
| | - Giacomo Montagna
- Universitätsspital Basel Switzerland, Department of Surgery, Basel, Switzerland
| | - Karol Polom
- Medical University of Gdansk, Department of Surgical Oncology, Gdansk, Poland
| | - Florian Primavesi
- Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck, Austria
| | - Yvonne Schrage
- Leiden University Medical Center, Department of Surgery, Leiden, Netherlands
| | | | - Tibor Kovacs
- Breast Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Domenico D'Ugo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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22
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Gianotti L, Sandini M, Hackert T. Preoperative carbohydrates: what is new? Curr Opin Clin Nutr Metab Care 2020; 23:262-270. [PMID: 32412978 DOI: 10.1097/mco.0000000000000661] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to give an overview of recently published articles covering preoperative carbohydrate loading in surgical patients. RECENT FINDINGS Between January 1, 2017, and December 31, 2019, 26 publications addressing the effect of carbohydrate load were retrieved through a systematic search. Seventeen were randomized clinical trials, three prospective observational studies and six retrospective series with case-control comparison. Most of the studies were underpowered, addressed surrogate endpoints, and variability among dose and timing of carbohydrate (CHO) treatment was high. The most recent literature endorses preoperative carbohydrate loading up to 2 h before operations as a safe treatment. The new evidence confirm that this strategy is effective in reducing perioperative insulin resistance and the proportion of hyperglycemia episodes, and improving patient well-being and comfort but without affecting surgery-related morbidity. SUMMARY Further properly designed randomized clinical trials, addressing more clinically relevant endpoints such as length of hospitalization and morbidity rate, are warrant.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University
- Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marta Sandini
- School of Medicine and Surgery, Milano - Bicocca University
- Department of Surgery, San Gerardo Hospital, Monza, Italy
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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23
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Goretti G, Marinari GM, Vanni E, Ferrari C. Value-Based Healthcare and Enhanced Recovery After Surgery Implementation in a High-Volume Bariatric Center in Italy. Obes Surg 2020; 30:2519-2527. [PMID: 32096016 PMCID: PMC7260281 DOI: 10.1007/s11695-020-04464-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients' adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients' engagement and outcomes. METHOD A multiprofessional team redesigned the process considering ERAS recommendations and patients' feedbacks. Outcomes that matter to patients were defined with structured patients' interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. RESULTS A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. CONCLUSION Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients' engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.
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Affiliation(s)
- Giulia Goretti
- Quality Department, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy.
| | - Giuseppe M Marinari
- Bariatric Surgery, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
| | - Elena Vanni
- Performance audit, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
| | - Chiara Ferrari
- Anesthesia, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
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Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care. Clin Nutr 2020; 39:2014-2024. [DOI: 10.1016/j.clnu.2019.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
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Hu Q, Yang X. Comment on "Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy". J Surg Oncol 2020; 122:360. [PMID: 32419143 DOI: 10.1002/jso.25954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Qiang Hu
- Department of General Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Xiyin Yang
- Department of Traditional Chinese Medicine, Community Health Service Center of Guali Town of Xiaoshan, Hangzhou, China
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Hur H, Roh CK, Son S, Han S. How could we make clinical evidence for early recovery after surgery (ERAS) in minimally invasive surgery for gastric cancer? J Surg Oncol 2020; 122:361-362. [DOI: 10.1002/jso.25955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Hoon Hur
- Division of Gastrointestinal Surgery, Department of Surgery Ajou University School of Medicine Suwon Korea
| | - Chul Kyu Roh
- Division of Gastrointestinal Surgery, Department of Surgery Ajou University School of Medicine Suwon Korea
| | - Sang‐Yong Son
- Division of Gastrointestinal Surgery, Department of Surgery Ajou University School of Medicine Suwon Korea
| | - Sang‐Uk Han
- Division of Gastrointestinal Surgery, Department of Surgery Ajou University School of Medicine Suwon Korea
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Téoule P, Birgin E, Mertens C, Schwarzbach M, Post S, Rahbari NN, Reißfelder C, Ronellenfitsch U. Clinical Pathways for Oncological Gastrectomy: Are They a Suitable Instrument for Process Standardization to Improve Process and Outcome Quality for Patients Undergoing Gastrectomy? A Retrospective Cohort Study. Cancers (Basel) 2020; 12:E434. [PMID: 32069805 PMCID: PMC7073178 DOI: 10.3390/cancers12020434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 12/24/2022] Open
Abstract
(1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before (n = 64) or after (n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.
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Affiliation(s)
- Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Christina Mertens
- Department of General and Visceral Surgery, Städtisches Klinikum Karlsruhe, Moltkestr.90, 76133 Karlsruhe, Germany;
| | - Matthias Schwarzbach
- Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt, Germany;
| | - Stefan Post
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Nuh N. Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Christoph Reißfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Ernst-Grube-Str.40, 06120 Halle (Saale), Germany
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Roh CK, Son SY, Lee SY, Hur H, Han SU. Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy. J Surg Oncol 2020; 121:662-669. [PMID: 31930513 DOI: 10.1002/jso.25837] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION ClinicalTrials.gov (NCT01642953).
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Affiliation(s)
- Chul Kyu Roh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sook Young Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Patel GP, Hyland SJ, Birrer KL, Wolfe RC, Lovely JK, Smith AN, Dixon RL, Johnson EG, Gaviola ML, Giancarelli A, Vincent WR, Richardson C, Parrish RH. Perioperative clinical pharmacy practice: Responsibilities and scope within the surgical care continuum. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Gourang P. Patel
- Department of Pharmacy, Division of Pulmonary and Critical Care Medicine; Department of Anesthesiology, Rush Medical College, Rush University Medical Center Chicago; Illinois
| | - Sara J. Hyland
- Pharmacy Services; Grant Medical Center-OhioHealth; Columbus Ohio
| | - Kara L. Birrer
- Pharmacy Services; Orlando Regional Medical Center/Orlando Health; Orlando Florida
| | - Rachel C. Wolfe
- Department of Pharmacy; Barnes-Jewish Hospital; St. Louis Missouri
| | | | - April N. Smith
- Department of Pharmacy Practice; Creighton University; Omaha Nebraska
- Department of Pharmacy; CHI Immanuel Medical Center; Omaha Nebraska
| | - Russell L. Dixon
- Department of Trauma; Surgical, and Neurological Critical Care, St John Medical Center; Tulsa Oklahoma
| | - Eric G. Johnson
- Department of Pharmacy Services; University of Kentucky HealthCare; Lexington Kentucky
- Department of Pharmacy Practice and Science; University of Kentucky College of Pharmacy; Lexington Kentucky
| | - Marian L. Gaviola
- Department of Pharmacotherapy; University of North Texas System College of Pharmacy; Fort Worth Texas
| | - Amanda Giancarelli
- Pharmacy Services; Orlando Regional Medical Center/Orlando Health; Orlando Florida
| | | | - Carole Richardson
- Pharmacy Information Services; Emory Healthcare, Inc; Atlanta Georgia
| | - Richard H. Parrish
- Department of Pharmacy; St. Christopher's Hospital for Children; Philadelphia Pennsylvania
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