'Fast-track' multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation

Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial

BACKGROUND

Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients.

METHODS

We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength).

RESULTS

A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03).

CONCLUSION

Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery.

TRIAL REGISTRATION

The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .

Efficacy and Safety of Enhanced Recovery After Surgery Pathway in Minimally Invasive Colorectal Cancer Surgery: A Systemic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) has been proven valuable for colorectal cancer (CRC) patients who received traditional surgery. While for those receiving minimally invasive surgery (MIS), its efficacy and safety remain debatable. Materials and Methods: Databases, including PubMed, EMBASE, Cochrane libraries, and Web of science, were searched for relevant articles from their inception to February 23, 2022. Eligible articles were subjected to quality assessment and data extraction. The comparison between ERAS and traditional care (TC) was performed. Primary outcomes of this study were postoperative length of stay (LOS), postoperative complications, and mortality. Secondary outcomes were 30-day readmission, 30-day reoperation, time to the first anal exhaust, and defecation. Results: Thirteen cohort studies covering 4308 patients were included. Patients in the ERAS group had significantly shorter LOS (weight mean differences [WMD]: -1.89; 95% confidence interval [CI]: -2.33 to -1.45; P < .001), lower incidence of postoperative complications (risk ratios [RR]: 0.73; 95% CI: 0.5-0.88; P < .001), lower 30-day readmission rate (RR: 0.75; 95% CI: 0.61-0.92; P < .05), and shorter time to the first defecation (WMD: -1.93; 95% CI: -3.26 to -0.59; P < .001), but unimproved mortality, reoperation rate, and time to the first anal exhaust (P > .05) compared with those in the TC group. Conclusions: ERAS was effective and safe for CRC patients receiving MIS from a real-world perspective. Hence, the implementation of ERAS should be recommended for minimally invasive CRC surgery. Clinical Trial Registration Number: CRD42022321333.

Fast-track surgery nursing intervention in CRC patients with laparotomy and laparoscopic surgery

In this study, the application effect of fast-track surgery (FTS) nursing intervention in laparotomy and laparoscopic surgery for colorectal cancer (CRC) is investigated, and the optimal perioperative management strategy for CRC surgery is explored. One hundred thirty CRC patients are included in this study, in which 67 patients undergo laparotomy (Group A) and 63 patients undergo laparoscopic surgery (Group B). These patients were also randomly divided into traditional nursing subgroup (Group A1 [n = 33] and Group B1 [n = 31]) and FTS nursing subgroup (Group A2 [n = 34] and Group B2 [n = 32]). The general data of patients, pre-operative preparation, intra-operative data, postoperative recovery data, and postoperative complications are recorded. Both FTS and laparoscopic surgery can advance the anal exhaust time, and shorten postoperative fasting and water deprivation time, and the hospitalization time without increasing the incidence of complications. FTS has advantages in reducing the indwelling time of gastric tube and throat pain. Simultaneous implementation of FTS and laparoscopic surgery has the best effect on the postoperative recovery of CRC patients.

Iterative Changes in Risk-Stratified Pancreatectomy Clinical Pathways and Accelerated Discharge After Pancreaticoduodenectomy

BACKGROUND

Previous implementation of risk-stratified pancreatectomy clinical pathways (RSPCPs) decreased length of stay (LOS) following pancreaticoduodenectomy (PD). This study's primary aim was to measure the association of iterative RSPCP revisions with accelerated discharge and early postoperative outcomes.

METHODS

This is a retrospective cohort study of a prospectively maintained surgical database (10/2016-9/2020). In February 2019, revised RSPCPs were implemented with earlier nasogastric tube (NGT) removal (postoperative day [POD] 1 for low risk; POD 2 for high risk) and updated drain fluid amylase cutoffs for POD 1/POD 3 removal. Perioperative outcomes between original and revised pathways were compared. Predictors of accelerated discharge (defined as ≤ POD 5 for low risk; ≤ POD 6 for high risk) were identified.

RESULTS

There were 233 (36% high risk) patients in original and 131 (32% high risk) in revised RSPCPs. After revision, the rate of POD 1 NGT removal was higher while POD ≤ 3 drain removal was similar. Median LOS decreased for low risk (5 vs. 6 days, p = 0.011) and high risk (6 vs. 9 days, p = 0.005) with no increase in delayed gastric emptying, postoperative pancreatic fistula, or readmissions. With POD 1 NGT removal, diet tolerance was earlier without increased NGT reinsertions. In low-risk patients, younger age, POD 1 NGT removal, and POD ≤ 3 drain removal were independent predictors of accelerated discharge. In high-risk patients, POD 1 NGT removal and POD ≤ 3 drain removal were independent predictors of accelerated discharge.

CONCLUSIONS

Following iterative revisions in RSPCPs, LOS after PD decreased further without increasing readmissions, and NGTs were removed earlier without increased reinsertions. Early NGT and drain removal are modifiable practices within RSPCPs that are associated with accelerated discharge.

Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial

OBJECTIVES

Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy.

MATERIALS AND METHODS

We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively.

RESULTS

Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support.

CONCLUSIONS

While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.

Microvascular reconstruction in head and neck cancer - basis for the development of an enhanced recovery protocol

Introduction

Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. Several ERAS protocols for microvascular head and neck cancer reconstructions have been proposed, although most of these are based on extrapolated evidence from different surgical specialties. Results from the implementation of ERAS for these procedures are inconsistent.

Methods

The current study investigates our clinical experience of head and neck cancer reconstruction for the period of 2014-2016 with the aim of establishing a list of functional discharge criteria. By combining these with the current published knowledge on the subject, we developed an ERAS protocol.

Results

We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Most cases were squamous cell carcinoma (89%). The average LOS was 20.3 days in both groups. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Furthermore, we identified the following discharge criteria: adequate pain relief, ambulation, sufficient nutritional intake, normal infection-related blood parameter results and absence of fever, bowel function, and closure of tracheostomy.

Conclusion

Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer.

Daily use of a muscle pump activator device reduces duration of hospitalization and improves early graft outcomes post-kidney transplantation: A randomized controlled trial

INTRODUCTION

Kidney and simultaneous pancreas-kidney (SPK) transplant recipients can have prolonged postoperative hospitalization due to edema. Thrombo-embolic-deterrent (TED) stockings with intermittent pneumatic compression devices (TED+IPC) have been used to improve venous return during the perioperative period. The objective of this trial was to evaluate the effects of TED+IPC vs. muscle pump activator (MPA) devices on factors that could reduce postoperative complications and duration of hospitalization.

METHODS

In this single-center, prospective, randomized, controlled trial, 221 kidney and SPK transplant recipients were randomized to either wearing TED+IPC or MPA for six days postoperatively. Groups were compared with respect to postoperative urine output, lower limb edema, weight, days in hospital, mobility, serum creatinine, delayed graft function, need for dialysis, and lower extremity blood flow.

RESULTS

Patients in the MPA group had significantly higher urine output and less increase in mid-calf leg circumference and weight gain compared to the TED+IPC group (p=0.003, p=0.001, and p=0.003, respectively). The MPA group also experienced shorter hospitalization (p=0.038), higher femoral vein velocity (p=0.001), and took more steps (p=0.009). Incidence of delayed graft function (p=0.72) and number of dialysis runs (p=0.39) was not different between study groups. Subgroup analysis of primary endpoints in donation after cardiac death recipients and SPK recipients did not yield any significance between the study arms.

CONCLUSIONS

Postoperative use of the MPA device increases urine output, decreases leg edema, minimizes weight gain, and decreases duration of hospitalization after kidney transplantation. A larger and longer-term trial is needed to evaluate the impact on graft function.

Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China

BACKGROUND

Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function.

METHODS

This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators.

RESULTS

The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023).

CONCLUSION

Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Reduction rate of C-reactive protein as an early predictor of postoperative complications and a reliable discharge indicator after gastrectomy for gastric cancer

Purpose

Postoperative complications (PCs) after gastrectomy are associated with readmission and longer hospital stay. This study aimed to determine the role of CRP as an early predictor of PCs and a reliable discharge indicator after gastrectomy.

Methods

Clinicopathologic data and PCs of 613 patients who underwent gastrectomy for gastric cancer in 2015–2016 were retrospectively analyzed, including consecutive blood samples for CRP obtained preoperatively, at the operative day, and postoperatively. Following the Clavien-Dindo classification, the patients were divided into a group with major PCs and a group with minor/no PCs. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Clinical factors related to major PCs were identified using univariate and multivariate logistic regression analyses.

Results

PCs occurred in 89 patients (14.5%). The most significant predictive factor for major PCs was a CRP concentration reduction rate of ≤38.1% (AUC, 0.82; sensitivity, 76.4%; specificity, 76.1%) between postoperative day (POD) 3 and 5 (R5), followed by ≤11.1% (AUC, 0.75; sensitivity, 73%; specificity, 76%) between POD 2 and 3 (R4). When both factors were applied (R4 ≤ 11.1% and R5 ≤ 38.1%), the specificity was 91.6%; when only one condition was satisfied (R4 ≤ 11.1% or R5 ≤ 38.1%), the sensitivity was 91%.

Conclusion

CRP concentration reduction rates between POD 3 and 5 and between POD 2 and 3 were the best combination factors to predict PCs and indicate a safe discharge after gastrectomy for gastric cancer.

Patient Satisfaction and Quality of Life with Enhanced Recovery Protocols

While studies have demonstrated the benefits of Enhanced Recovery after Surgery (ERAS) programs in reducing length of stay and costs without increasing complications, fewer studies have evaluated patient satisfaction and quality of life (QOL) with enhanced recovery protocols. The aim of this project was to summarize the literature comparing satisfaction and quality of life after colorectal surgery following treatment within an ERAS protocol to standard postoperative care. The available evidence suggests patients suffer no detriment to satisfaction or quality of life with use of ERAS protocols, and may suffer less fatigue and return to activities sooner. Most publications reported no adverse effects on postoperative pain. However, a limited number of studies suggest patients may experience increased early postoperative pain with ERAS pathways, particularly following open colorectal procedures. Future research should focus on potential improvements in ERAS protocols to better manage postoperative pain. Overall, the evidence supports more widespread implementation of ERAS pathways in colorectal surgery.

Use of Epidural Analgesia in Sigmoidectomy: Is There Any Advantage in the Era of Minimally Invasive Surgery?

BACKGROUND

There is no consensus as to the effects of epidural analgesia on postoperative outcomes after laparoscopy in the context of the Enhanced Recovery Programs. The aim of this study was to evaluate the effects of epidural analgesia on postoperative outcomes after elective laparoscopic sigmoidectomy.

METHODS

The use of epidural analgesia was discontinued in elective laparoscopic sigmoidectomy and substituted by the perioperative administration of systemic lidocaine. Data from patients undergoing elective laparoscopic sigmoidectomy between January 2014 and September 2016 was prospectively analysed. Patients with epidural analgesia were compared with patients without, in analgesics administrated postoperatively, length of stay, day of first defecation and mobilisation, and complication and reoperation rates.

RESULTS

A total of 160 patients (male 85; female 75), median age 68 (30-92 years), were included. The groups consisted of 80 patients each. Mean length of stay (5.6 vs. 7.2 days, p = 0.03) and day of first mobilisation (mean 1.2 vs. 1.6 days, p = 0.004) were significantly shorter in the group without epidural analgesia. Reoperation rate (7.5 vs. 2.5%) was not statistically different. Complication rate was significantly lower (12.5 vs. 30%, p = 0.007) in the group without epidural. Day of first defecation was shorter in the epidural group (1.4 vs. 1.7 days, p = 0.04). Mean amount of analgesics administrated was not statistically different between groups, except for metamizole, that was administrated more in the group without epidural.

CONCLUSIONS

Epidural analgesia did not offer benefits on postoperative analgesia or outcomes after elective laparoscopic sigmoidectomy, causing longer length of stay, later mobilisation and higher complication rate.

Enhanced Recovery After Surgery and Its Effects on Patient Reported Outcomes

Enhanced recovery programs were developed as a means for improving patient recovery after surgery with a multifaceted approach including several interventions in the perioperative period. There is now sufficient evidence in the literature that enhanced recovery programs have actually shortened hospital length of stay after colorectal surgery. Nonetheless, the impact of these successful programs on patient-reported outcomes like functional recovery and return to baseline quality of life is not known.

A meta-analysis of short-term outcome of laparoscopic surgery versus conventional open surgery on colorectal carcinoma

OBJECTIVE

The aim of this article is to study the superiority and safety of laparoscopic surgery for colorectal carcinoma.

SUMMARY BACKGROUND DATA

Laparoscopy in rectal cancer is still not recommended as the treatment of choice by National Comprehensive Cancer Network guidelines. Laparoscopic rectal surgery is more complex and technically demanding, especially for mid and low rectal cancer.

METHODS

A computer-based online research of retrospective or prospective studies addressing laparoscopic surgery versus conventional open surgery for colorectal carcinoma published in the last 11 years was performed in electronic database (Wangfang Database, China National Knowledge Infrastructure, Chinese Medical Current Contents, Pubmed, Medline, Ovid, Elsevier, ISI Web of Knowledge, Cohrane Database of Systematic Reviews). Selective trials were analyzed by the Review Manager 5.2 software.

RESULTS

A total of 9 clinical trials, involving a total of 4747 patients, were identified. A meta-analysis showed that operating time was not significantly different between the 2 groups [WMD = 0.46, 95% confidence interval (95% CI): -55.68 to 56.60, P = .99], intraoperative blood loss in laparoscopic surgery group was less than conventional open surgery group (WMD = -64.66, 95% CI: -87.31 to 42.01, P < .01); No significant difference in the number of lymph node retrieved from postoperative pathologic specimens was found between the 2 groups (WMD = -0.75, 95% CI: -1.72 to 0.23, P = .14); Postoperative time to flatus in laparoscopic surgery group was earlier than that in open surgery significantly (WMD = -1.22, 95% CI: -1.53 to -0.91, P < .01). The cases of postoperative complications were significantly different between the 2 groups, which showed that the cases of laparoscopic surgery group were less than those of open surgery group [odds ratio (OR) = 0.62, 95% CI: 0.52∼0.72, P < .01]; Moreover, hospital stay of laparoscopic surgery group was shorter than that of open surgery that showed significant difference (WMD = -2.38, 95% CI:-3.30 to -1.46, P < .01).

CONCLUSION

Short-term outcomes of laparoscopic surgery are superior than conventional open surgery that include more safety and feasibility, and is expected to be a standardization operation method for colorectal carcinoma.

Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system

Background

Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).

Methods

ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.

Results

Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.

Conclusions

Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

The use of alvimopan for postoperative ileus in small and large bowel resections

Transient ileus is a normal physiologic process after surgery. When prolonged, it is an important contributor to postoperative complications, increased length of stay and increased healthcare costs. Efforts have been made to prevent and manage postoperative ileus; alvimopan is an oral, peripheral μ-opioid receptor antagonist, and the only currently US FDA-approved medication to accelerate the return of gastrointestinal function postoperatively.

Ice Reduces Needle-Stick Pain Associated With Local Anesthetic Injection

BACKGROUND

Local anesthetic injections are widely used in the emergency department for different purposes. Pain management for such injections is of great importance to both patients and the healthcare system.

OBJECTIVES

Our study aimed to determine the effectiveness and safety of cryotherapy in patients receiving local anesthetic injections.

METHODS

Subjects who presented with superficial lacerations were randomly assigned to 2 groups, the first group received ice packing prior to injection and the second did not. The pain severity, length and depth of the laceration, and the other necessary information before and after the pain-reducing intervention were measured, documented, and compared at the end of the study. Pain scores were measured using a numerical rating scale before and after the procedure, and the differences were compared using a t-test.

RESULTS

Ninety subjects were enrolled in the study, 45 in each group. There were no statistical differences between the 2 groups in terms of baseline preoperative and operative characteristics (P > 0.05). The pain scores in the cryotherapy group were significantly lower before and after the procedure (P < 0.001). There was no statistically significant difference between the 2 groups for wound infection (P = 0.783).

CONCLUSIONS

Cooling the injection site prior to local anesthetic injection is an effective and inexpensive method to reduce the pain and discomfort caused by the injection.

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making

BACKGROUND

Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters.

METHODS

We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) ).

RESULTS

In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism.

CONCLUSION

This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare professionals the opportunity to identify vulnerable patients in ambulatory surgery, although additional modification and validation are needed. (ClinicalTrials.gov number, NCT01441843).

Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection

Background

Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection.

Methods

A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups.

Results

126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4–7) vs. 5 (IQR 4–6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56–2.62, p = 0.627).

Conclusions

Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.

Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described.

METHOD

MEDLINE, Embase and the Cochrane Database of Systematic Reviews (up to July 2014) were searched. Two authors independently reviewed citations using predefined inclusion and exclusion criteria.

RESULTS

The search strategy yielded 3233 citations; 54 were eligible, comprising 18 983 patients. Twenty-six studies were prospective [17 of these being randomized controlled trials (RCTs)] and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3% (95% CI 8.4-12.5) and 10.2% (95% CI 5.6-17.8) for non-RCTs and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for RCTs. The used definition of PPOI, the type of surgery and access (laparoscopic, open) and the duration of surgery lead to significant variability of reported PPOI incidence between studies. The incidence of PPOI is lower after laparoscopic colonic resection.

CONCLUSION

There is a large variation in the reported incidence of PPOI. A uniform definition of PPOI is needed to allow meaningful inter-study comparisons and to evaluate strategies to prevent PPOI.

Nausea, vomiting and return of bowel function after colorectal surgery

BACKGROUND

Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context.

METHOD

Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12.

RESULTS

A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related.

CONCLUSION

Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.

Fast-track protocols in devascularization for cirrhotic portal hypertension

INTRODUCTION/OBJECTIVE

fast-tract surgery (FTS) has been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. The aim of this study was to determine if any improvement in outcomes occurred after FTS protocol for selective double portazygous disconnection with preserving vagus (SDPDPV) compared with non-FTS postoperative care.

METHODS

patients eligible for SDPDPV in the period January 2012-April 2014 were randomly selected for the FTS group or non-FTS group. A designed protocol was used in the FTS group with emphasis on an interdisciplinary approach. The non-FTS group was treated using previously established standard procedures. The number of postoperative complications, time of functional recovery and duration of hospital stay were recorded.

RESULTS

patients in the FTS group (n=59) and non-FTS group (n=57) did not differ in terms of preoperative data and operative details (p>0.05). The FTS procedure led to significantly better control and faster restoration of gastrointestinal functions, food tolerance, rehabilitation and hospital discharge (p<0.05). Postoperative complications, including nausea/vomiting, severe ascites, wound infection, urinary tract infection and pulmonary infection were all significantly lower in the FTS group (p<0.05). According to the postoperative morbidity classification used by Clavien, overall complications and grade I complications were both significantly lower in the FTS group compared with the non-FTS group (p<0.05).

CONCLUSION

adopting the FTS protocol helped to recover gastrointestinal functions, to reduce frequency of postoperative complications and to reduce hospital stay. The FTS strategy is safe and effective in improving postoperative outcomes.

Fast-track laparoscopic surgery: A better option for treating colorectal cancer than conventional laparoscopic surgery

Fast-track surgery (FTS), a multimodal rehabilitation technique, has been recommended as surgical therapy for colorectal cancer. The objective of the present study was to compare the outcomes of FTS and conventional laparoscopic surgery. This study was a blinded randomized trial. A total of 70 patients with colorectal cancer were divided into two groups and underwent laparoscopic colorectal resection. The FTS group consisted of 31 patients and the control group consisted of 39 patients. Protocols for the treatment of the FTS group included skipping pre-operative mechanical bowel preparation, early restoration of diet and early post-operative ambulation. Outcome measures, length of hospital stay, post-operative surgical stress response [C-reactive protein (CRP)] and post-operative complications were compared between the two groups. The average length of total hospital stay for the FTS and the control groups was 5.9±0.8 and 10.9±1.3 days, respectively (P<0.05), and the length of post-operative hospital stay for the FTS and control group was 4.3±0.8 and 8.0±1.1 days, respectively. (P<0.05) First flatus time for the FTS and control groups was 1.6±0.8 and 2.5±0.9 days, respectively (P<0.05). Defecation time for the FTS and control groups was 2.2±0.7 and 4.5±0.7 days, respectively (P<0.05). The time to restoration of a solid diet also showed a significant difference between the FTS and control groups (1.1±0.3 vs. 3.6±0.9 days; P<0.05). Following surgery, due to post-operative surgical stress, the two groups CRP levels increased significantly, but the levels of the FTS group were lower than those of the conventional control group (P<0.05). There was no difference in post-operative complications between the FTS and control groups. This study confirms that FTS shortens hospital stay and accelerates the recovery of bowel function without increase of post-operative complications. FTS is safe, improves post-operative recovery and is a better option than conventional laparoscopic surgery for treating colorectal cancer patients.

Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme

BACKGROUND

In recent years, conventional colorectal resection and its aftercare have increasingly become replaced by laparoscopic surgery and enhanced recovery after surgery (ERAS) pathways, respectively.

OBJECTIVE

To ascertain whether combining laparoscopy and ERAS have additional value within colorectal surgery.

METHODS

A systematic review with meta-analysis was performed with two primary research questions; does laparoscopy offer an advantage when all patients receive ERAS perioperative care and does ERAS offer advantages in a laparoscopically operated patient population. All randomised and controlled clinical trials were identified using MEDLINE, EMBASE and Cochrane databases.

RESULTS

Primary search resulted in 319 hits. After inclusion criteria were applied, three RCTs and six CCTs were included in the meta-analysis. For laparoscopically operated patients with/without ERAS, no differences in morbidity were found and postoperative hospital stay favoured ERAS (MD -2.34 [-3.77, -0.91], Z = 3.20, p = 0.001). When comparing laparoscopy and open surgery within ERAS, major morbidity was significantly reduced in the laparoscopic group (OR 0.42 [0.26, 0.66], Z = 3.73, p = 0.006). Other outcome parameters showed no differences. Quality of included studies was considered moderate to poor overall with small sample sizes.

CONCLUSION

When laparoscopy and ERAS are combined, major morbidity and hospital stay are reduced. The reduction in morbidity seems to be due to laparoscopy rather than ERAS, so laparoscopy by itself offers independent advantages beyond ERAS care. Quality of included studies was moderate to poor, so conclusions should be regarded with some reservations.

Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery.

METHODS

We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included.

RESULTS

A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46-0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27-0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54-1.08)]. The ERAS pathway shortened hospital stay (WMD = -2.28 days [95 % CI -3.09 to -1.47]), without increasing readmission rate.

CONCLUSIONS

The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.

What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways?

PURPOSE

The purpose of this narrative review is to provide a framework from which to measure the outcomes of Enhanced Recovery After Surgery (ERAS) programs.

PRINCIPLE FINDINGS

We define the outcomes of recovery from the perspective of different stakeholders and time frames. There is no single definition of recovery. There are overlapping phases of recovery which are of particular interest to different stakeholders (surgeons, anesthesiologists, nurses, patients and their caregivers), and the primary outcome of interest may vary depending on the phase and the perspective. In the earliest phase (from the end of the surgery to discharge from the postanesthesia care unit [PACU]), biologic and physiologic outcomes are emphasized. In the intermediate phase (from PACU to discharge from the hospital), symptoms related to pain and gastrointestinal function as well as basic activities are important. Studies of ERAS pathways have reported clinical outcomes and symptoms, including complications, hospital stay, mobilization, and gastrointestinal function, largely during hospitalization. Nevertheless, patients define recovery as return to normal functioning, a process that occurs over weeks to months (late phase). Outcomes reflecting functional status (e.g., physical activity, activities of daily living) and overall health (e.g., quality of life) are important in this phase. To date, few studies reporting the effectiveness of ERAS pathways compared with conventional care have included functional status or quality-of-life outcomes, and there is little information about recovery after discharge from hospital.

CONCLUSION

Recovery after surgery is a complex construct. Different outcomes are important at different phases along the recovery trajectory. Measures for quantifying recovery in hospital and after discharge are available. A consensus-based core set of outcomes with input from multiple stakeholders would facilitate research reporting.

Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery

INTRODUCTION

Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug (NSAID) use after colorectal resection. The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery.

METHODS

A retrospective review (2004-2011) was performed on patients who underwent elective colorectal surgery. Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate.

RESULTS

A total of 731 patients were identified as having resection with primary anastomosis: 376 (51.4 %) received no NSAIDs and 355 (48.6 %) received ketorolac perioperatively within 5 days after their surgery. There were 24 (3.3 %) leaks, with 12 in both the no NSAIDs (3.2 %) and ketorolac (3.4 %) groups, odds ratio (OR) 1.06 (0.43, 2.62; p = 0.886). Adjusting for smoking, steroid use, and age, there remained no significant difference between ketorolac use and leakage, OR 1.21 (0.52, 2.84; p = 0.660). In our multivariate model, only smoking was a significant predictor of postoperative leak, OR 3.34 (1.30, 8.62; p = 0.021).

CONCLUSIONS

There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery. However, further prospective studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended.

Integrating hospital administrative data to improve health care efficiency and outcomes: "the socrates story"

Evaluation of health care outcomes has become increasingly important as we strive to improve quality and efficiency while controlling cost. Many groups feel that analysis of large datasets will be useful in optimizing resource utilization; however, the ideal blend of clinical and administrative data points has not been developed. Hospitals and health care systems have several tools to measure cost and resource utilization, but the data are often housed in disparate systems that are not integrated and do not permit multisystem analysis. Systems Outcomes and Clinical Resources AdministraTive Efficiency Software (SOCRATES) is a novel data merging, warehousing, analysis, and reporting technology, which brings together disparate hospital administrative systems generating automated or customizable risk-adjusted reports. Used in combination with standardized enhanced care pathways, SOCRATES offers a mechanism to improve the quality and efficiency of care, with the ability to measure real-time changes in outcomes.

Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery

OBJECTIVE

To perform a systematic review of interventions used to reduce adverse events in surgery.

BACKGROUND

Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001).

CONCLUSIONS

Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.

Systematic review of outcomes used to evaluate enhanced recovery after surgery

BACKGROUND

Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies.

METHODS

A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge).

RESULTS

A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission.

CONCLUSION

Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.

Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target?

PURPOSE

The complexity of "fast track" (FT) surgery might decrease its applicability in daily practice and extensive diffusion. The aim of this study was to understand if the positive effect of FT on the outcome might be affected by the number, type, level of evidence of the components, or their possible combinations.

METHODS

We performed a Medline, Embase, Pubmed, and Cochrane Library literature search of randomized and non-randomized trials comparing FT to conventional care (CC) in elective colorectal operations. By a meta-analytic approach, the effect of FT was estimated by the risk ratio (RR) with a 95 % confidence interval (CI) for the risk of post-operative complications.

RESULTS

The analysis included 53 studies (36 non-RCTs with and 17 RCTs), with 4,100 patients in the FT group and 4,424 patients in the CC group for a total of 8,524 patients. Fifty-six different item combinations were observed. The median rate of strategy implementation was 50 %. The positive effect of FT over CC was observed regardless the number (<10 vs. ≥10) of strategies used (RR = 0.80; 95 % CI 0.66-0.98 and RR = 0.75; 95 % CI 0.65-0.87, respectively), the application of items with strong vs. low level evidence (RR = 0.78; 95 % CI 0.67-0.90 and RR = 0.76; 95 % CI 0.63-0.92, respectively), or the frequency (≥80 vs. <80 %) of items implemented (RR = 0.80; 95 % CI 0.69-0.93 and RR = 0.73; 95 % CI 0.61-0.87, respectively).

CONCLUSION

The positive effects of FT seem to be achieved regardless the multiplicity and variance of item grouping.

Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery

The aim of this prospective cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol (FT) and these factors' influences on postoperative outcomes. A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors, the outcome variables, and the items of the FT program. The median length of stay was 5 days, and readmission rate was 2.3%. The morbidity rate was 26.7%. Independent predictors of prolonged length of stay were older than 75 years of age, ASA grade 3 and 4, and the presence of an ileostomy. Independent predictors of morbidity were age above 75 years old and ASA grade, whereas age was confirmed as an independent predictor of mortality. Male sex, age above 75 years old, and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items.

A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery

AIM

The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period.

METHOD

A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates.

RESULTS

The overall median HS was 7 days. The median HS for laparoscopy + FT was 5 days, open + FT 6 days, laparoscopy + CC 9 days and open + CC 10 days (P < 0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P < 0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P < 0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points.

CONCLUSION

Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.

Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway

BACKGROUND

After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use.

OBJECTIVE

The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes.

DESIGN

This was a case-matched study.

METHODS

After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex.

SETTINGS

This study was performed at a tertiary referral center.

PATIENTS

Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included.

MAIN OUTCOME MEASURES

The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway.

RESULTS

Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen.

LIMITATIONS

The single-surgeon, single-institution design was a limitation of this study.

CONCLUSIONS

The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

Association between quality of care and complications after abdominal surgery

BACKGROUND

Measuring the quality of surgical care is essential to identifying areas of weakness in the delivery of effective surgical care and to improving patient outcomes. Our objectives were to (1) assess the quality of surgical care delivered to adult patients; and (2) determine the association between quality of surgical care and postoperative complications.

METHODS

This retrospective, pilot, cohort study was conducted at a single university-affiliated institution. Using the institution's National Surgical Quality Improvement Program database (2009-2010), 273 consecutive patients ≥18 years of age who underwent elective major abdominal operations were selected. Adherence to 10 process-based quality indicators (QIs) was measured and quantified by calculating a patient quality score (no. of QIs passed/no. of QIs eligible). A pass rate for each individual QI was also calculated. The association between quality of surgical care and postoperative complications was assessed using an incidence rate ratio, which was estimated from a Poisson regression.

RESULTS

The mean overall patient quality score was 67.2 ± 14.4% (range, 25-100%). The mean QI pass rate was 65.9 ± 26.1%, which varied widely from 9.6% (oral intake documentation) to 95.6% (prophylactic antibiotics). Poisson regression revealed that as the quality score increased, the incidence of postoperative complications decreased (incidence rate ratio, 0.19; P = .011). A sensitivity analysis revealed that this association was likely driven by the postoperative ambulation QI.

CONCLUSION

Higher quality scores, mainly driven by early ambulation, were associated with fewer postoperative complications. QIs with unacceptably low adherence were identified as targets for future quality improvement initiatives.

Liposome Bupivacaine for Postsurgical Analgesia in Adult Patients Undergoing Laparoscopic Colectomy: Results from Prospective Phase IV Sequential Cohort Studies Assessing Health Economic Outcomes

Background

Opioid-based postsurgical analgesia exposes patients undergoing laparoscopic colectomy to elevated risk for gastrointestinal motility problems and other opioid-related adverse events (ORAEs). The purpose of our research was to investigate postsurgical outcomes, including opioid consumption, hospital length of stay, and ORAE risk associated with a multimodal analgesia regimen, employing a single administration of liposome bupivacaine as well as other analgesics that act by different mechanisms.

Methods

We analyzed combined results from 6 Phase IV, prospective, single-center studies in which patients undergoing laparoscopic colectomy received opioid-based intravenous patient-controlled analgesia (PCA) or multimodal analgesia incorporating intraoperative administration of liposome bupivacaine. As-needed rescue therapy was available to all patients. Primary outcome measures were postsurgical opioid consumption, hospital length of stay, and hospitalization costs. Secondary measures included time to first rescue opioid use, patient satisfaction with analgesia (assessed using a 5-point Likert scale), and ORAEs.

Results

Eighty-two patients underwent laparoscopic colectomy and did not meet intraoperative exclusion criteria (PCA n = 56; multimodal analgesia n = 26). Compared with the PCA group, the multimodal analgesia group had significantly lower mean total postsurgical opioid consumption (96 vs 32 mg, respectively; P < 0.0001) and shorter median postsurgical hospital length of stay (3.0 vs 4.0 days; P = 0.0019). Geometric mean costs were $11,234 and $13,018 in the multimodal analgesia and PCA groups, respectively (P = 0.2612). Median time to first rescue opioid use was longer in the multimodal analgesia group versus PCA group (1.1 hours vs 0.6 hours, respectively; P=0.0003). ORAEs were experienced by 41% of patients receiving intravenous opioid PCA and 8% of patients receiving multimodal analgesia (P = 0.0019). Study limitations included use of an open-label, nonrandomized design; small population size; and the inability to isolate treatment-related effects specifically attributable to liposome bupivacaine.

Conclusions

Compared with intravenous opioid PCA, a liposome bupivacaine-based multimodal analgesia regimen reduced postsurgical opioid use, hospital length of stay, and ORAEs, and may lead to improved postsurgical outcomes following laparoscopic colectomy.

Safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy for gastric cancer: a randomized clinical trial

BACKGROUND

Fast-track surgery has been shown to enhance postoperative recovery in several surgical fields. This study aimed to evaluate the safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy.

METHODS

The present study was designed as a single-center, randomized, unblinded, parallel-group trial. Patients were eligible if they had gastric cancer for which laparoscopic distal gastrectomy was indicated. The fast-track surgery protocol included intensive preoperative education, a short duration of fasting, a preoperative carbohydrate load, early postoperative ambulation, early feeding, and sufficient pain control using local anesthetics perfused via a local anesthesia pump device, with limited use of opioids. The primary endpoint was the duration of possible and actual postoperative hospital stay.

RESULTS

We randomized 47 patients into a fast-track group (n=22) and a conventional pathway group (n=22), with three patients withdrawn. The possible and actual postoperative hospital stays were shorter in the fast-track group than in the conventional group (4.68±0.65 vs. 7.05±0.65; P<0.001 and 5.36±1.46 vs. 7.95±1.98; P<0.001). The time to first flatus and pain intensity were not different between groups; however, a greater frequency of additional pain control was needed in the conventional group (3.64±3.66 vs. 1.64±1.33; P=0.023). The fast-track group was superior to the conventional group in several factors of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, including: fatigue, appetite loss, financial problems, and anxiety. The complication and readmission rates were similar between groups.

CONCLUSIONS

Fast-track surgery could enhance postoperative recovery, improve immediate postoperative quality of life, and be safely applied in laparoscopic distal gastrectomy.

Management of prolonged post-operative ileus: evidence-based recommendations

BACKGROUND

Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management.

METHODS

A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C).

RESULTS

Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C).

CONCLUSIONS

Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.

Fast-track colorectal surgery: protocol adherence influences postoperative outcomes

PURPOSE

This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery.

METHODS

From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay-LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures-100 %, 85-95 %,70-80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables.

RESULTS

Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011).

CONCLUSION

Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.

Enhanced recovery after surgery versus conventional care in colonic and rectal surgery

INTRODUCTION

Enhanced recovery after surgery (ERAS) programmes have been shown to improve outcomes after colonic surgery. However, there is less evidence supporting ERAS in rectal surgery. The aim of this study was to compare outcomes of conventional perioperative care with those of an ERAS pathway including both colonic and rectal surgery patients.

METHODS

Outcomes of patients undergoing elective colorectal surgery at Christchurch Hospital within the ERAS pathway were compared with patients receiving conventional perioperative care over a 2-year period. A retrospective analysis was conducted, including primary and total length of stay (LOS), readmission, complication and mortality rate.

RESULTS

A total of 240 patients undergoing colorectal surgery were included; 160 patients received conventional perioperative care and 80 patients were managed within the ERAS pathway. Primary and total LOS were shorter in the ERAS group (6 versus 7 days, P = 0.0004, 7 versus 10 days, P = 0.0003, respectively). Re-admission and complication rates were not significantly different between the groups. There was one death (in the conventional care group) within 30 days. Patients undergoing rectal surgery within the ERAS pathway did not show any difference in primary LOS, readmission or complication rate although median total LOS was significantly reduced (7 versus 10 days, P = 0.0457).

CONCLUSION

Patients undergoing elective colorectal surgery managed within the ERAS pathway had shorter hospital stays without increased morbidity or mortality. Differences were less pronounced in the rectal surgery subgroup and further research is needed to investigate the use of ERAS pathways for patients undergoing elective rectal surgery.

Recovery of upper gastrointestinal bowel movement after rectosigmoid cancer surgery: a pilot transit analysis

Postoperative gastrointestinal bowel transit right after colorectal resection has not yet been clarified. Thirty patients with rectosigmoid cancer were treated in this pilot study. The nasogastric tube was removed on the first postoperative day. One Sitzmarks capsule was given to each patient on the second postoperative day. Abdominal X-rays were taken at 3, 6, 8, 24, 48, and 72 hours after capsule intake. Distribution of the remaining Sitzmarks capsules were counted on X-ray films to clarify postoperative gastrointestinal movement after bowel resection. All Sitzmarks capsules were observed in the stomach at 3 and 6 hours after capsule intake. At 8 hours (second postoperative day), the Sitzmarks capsules were distributed from the stomach to the small intestine. Sitzmarks capsules were distributed in the right side colon at 24 hours (third postoperative day) after intake. Although the main distribution was still in the right side colon, several patients had evacuations accompanied by the disappearance of the Sitzmarks capsules. In 50% of the patients, it took approximately 72 hours (fifth postoperative day) for the first defecation after intake of the capsules. However, the Sitzmarks capsules remained mainly in the right side colon. Eight hours after intake, the majority of the Sitzmarks capsules shifted to the small intestine. Therefore, medication or feeding should be safely possible starting on the second postoperative day. There was no particular impact of bowel resection on upper gastrointestinal transit in patients with rectosigmoid cancer.