Clinical and Economic Impact of an Enhanced Recovery Pathway for Open and Laparoscopic Rectal Surgery

Laparoscopy is non-inferior to open surgery for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery has been endorsed by clinical guidelines for colon cancer, but not for rectal cancer on account of unapproved oncologic equivalence with open surgery.

AIMS

We started this largest-to-date meta-analysis to comprehensively evaluate the safety and efficacy of laparoscopy in the treatment of rectal cancer compared with open surgery.

MATERIALS & METHODS

Both randomized and nonrandomized controlled trials comparing laparoscopic proctectomy and open surgery between January 1990 and March 2020 were searched in PubMed, Cochrane Library and Embase Databases (PROSPERO registration number CRD42020211718). The data of intraoperative, pathological, postoperative and survival outcomes were compared between two groups.

RESULTS

Twenty RCTs and 93 NRCTs including 216,615 patients fulfilled the inclusion criteria, with 48,888 patients received laparoscopic surgery and 167,727 patients underwent open surgery. Compared with open surgery, laparoscopic surgery group showed faster recovery, less complications and decreased mortality within 30 days. The positive rate of circumferential margin (RR = 0.79, 95% CI: 0.72 to 0.85, p < 0.0001) and distal margin (RR = 0.75, 95% CI: 0.66 to 0.85 p < 0.0001) was significantly reduced in the laparoscopic surgery group, but the completeness of total mesorectal excision showed no significant difference. The 3-year and 5-year local recurrence, disease-free survival and overall survival were all improved in the laparoscopic surgery group, while the distal recurrence did not differ significantly between the two approaches.

CONCLUSION

Laparoscopy is non-inferior to open surgery for rectal cancer with respect to oncological outcomes and long-term survival. Moreover, laparoscopic surgery provides short-term advantages, including faster recovery and less complications.

Enhanced Recovery After Surgery Protocol for Oblique Lumbar Interbody Fusion

BACKGROUND

Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it has not been widely utilized in spinal surgery. The study reported the development and implementation of an ERAS pathway for patients with lumbar spondylolisthesis undergoing oblique lumbar interbody fusion (OLIF).

METHODS

Seventy-six patients underwent OLIF surgery from January 2018 to December 2019 were enrolled. Thirty-seven patients were included in pre-ERAS group and 39 patients were included in ERAS group. Major outcomes that were collected included demographics, comorbidities, blood loss, operative time, length of hospital stay (LOS), cost, time to walk, blood transfusion, complications, Visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and factors affecting LOS were also recorded. The ERAS pathway and compliance with pathway elements were also recorded.

RESULTS

After ERAS implementation, the blood loss, LOS, the financial costs, and the time to walk were significantly lower in the ERAS group compared to the pre-ERAS group (all P < 0.05). There was no significant difference in operative time, complications, and blood transfusion between both groups. VAS and ODI between the two groups showed a significant difference during postoperative 3 days and postoperative 1 month (both P < 0.05). The preoperative time to walk was significant factors for hospital stay at the final follow-up.

CONCLUSION

Institution of an ERAS protocol for OLIF surgery appears to accelerate functional recovery, reduce length of stay and financial costs.

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

BACKGROUND

Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.

MATERIALS EN METHODS

The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.

RESULTS

152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).

CONCLUSION

An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

Financial implications of trauma patients at a Canadian level 1 trauma center: a retrospective cohort study

Background

Trauma is a cause of significant morbidity and mortality globally, and patients with major trauma require specialized settings for multidisciplinary care. We sought to enumerate the variability of costs of caring for patients at a Canadian level 1 trauma center.

Methods

A retrospective analysis of all adult patients admitted to The Ottawa Hospital trauma service between June 2013 and June 2018 was conducted. Hospital costs and clinical data were collected. Descriptive statistics and multivariable regression analysis using generalized linear model were performed to assess cost variation with patient characteristics. Quintile-based analyses were used to characterize patients in different cost categories. Hospital costs were reported in 2018 Canadian dollars.

Results

A total of 2381 admissions were identified in the 5-year cohort. The mean age of patients was 50.2 years, the mean Injury Severity Score (ISS) was 18.7, the mean Charlson Comorbidity Index (CCI) score was 0.35, and the median total cost was $10 048.54. ISS and CCI score were associated with higher costs (ISS >15; p<0.0001). The most expensive mechanisms of injury (MOIs) were those involving heavy machinery (median total cost $24 074.38), pedestrians involved in road traffic collisions ($20 965.45), patients in motor vehicle collisions ($17 621.01) and motorcycle collisions ($16 220.89), and acts of self-injury ($13 903.69). Patients who experienced in-hospital adverse events were associated with higher costs (p<0.0001). Our multivariable regression analysis showed variation in costs related to male gender, penetrating/violent MOI, ISS, adverse hospital events, CCI score, urgent admission status, hospital 1-year mortality risk score, and alternate level of care designation (p<0.05). Quintile-based analyses demonstrated clinically significant differences between the highest and lowest cost groups.

Discussion

Major trauma was associated with high hospital costs. Modifiable and non-modifiable patient factors were shown to correlate with differing total hospital costs. These findings can aid in the development of funding strategies and resource allocation for this complex patient population.

Level of evidence

Level III evidence for economic and value-based evaluations.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

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.