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Tolmay S, Rahiri JL, Snoep K, Fewster G, Kee R, Lim Y, Watson B, Richter KK. Lessons following implementation of a colorectal enhanced recovery after surgery (ERAS) protocol in a rural hospital setting. ANZ J Surg 2024; 94:910-916. [PMID: 38205533 DOI: 10.1111/ans.18838] [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: 05/05/2023] [Revised: 11/24/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) programs have become increasingly popular in the management of patients undergoing colorectal resection. However, the validity of ERAS in rural hospital settings without intensive care facilities has not been primarily evaluated. This study aimed to assess an ERAS protocol in a rural surgical department based in Invercargill New Zealand. METHODS Ten years of prospectively collected data were analysed retrospectively from an ERAS database of all patients undergoing open, converted, or laparoscopic colorectal resections. Data were collected between two time periods: before the implementation of an ERAS protocol, from January 2011 to December 2013; as well as after the implementation of an ERAS protocol, from January 2014 to December 2020. The primary outcome measures were hospital length of stay (LOS) and LOS in the critical care unit (LOS-CCU). Secondary outcomes were compliance with ERAS protocol, mortality, readmission, and reoperation rates. RESULTS A total of 118 and 558 colorectal resections were performed in the pre-ERAS and ERAS groups respectively. A statistically significant reduction in hospital LOS was achieved from a median of 8 to 7 days (P = 0.038) when comparing pre-ERAS to ERAS groups respectively. Furthermore, a significant reduction in re-operation rates was observed (7.6% vs. 3% in the ERAS group, P = 0.033) which was seen without a rise in readmission rates (13.6% vs. 13.6% in the ERAS group). CONCLUSION The implementation of ERAS in a rural surgical setting is feasible, and these initial findings suggest ERAS adds value in optimizing the colorectal patient's surgical journey.
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Affiliation(s)
- Stephen Tolmay
- Department of Surgery, Waitematā District Health Board, Auckland, New Zealand
| | - Jamie-Lee Rahiri
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Kim Snoep
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Gillian Fewster
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Rachel Kee
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Yukai Lim
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Bridget Watson
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
| | - Konrad Klaus Richter
- Department of Surgery, Southland Hospital, Invercargill, New Zealand
- Dunedin School of Medicine, University of Otago, New Zealand
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Faria EF, Machado RD, Gualberto RJC, Milani MAV, Bidinotto LT, Machado MT, Dos Reis R, Bidinotto DNPB. Patient's safety and satisfaction on same day discharge after robotic and laparoscopic radical prostatectomy versus discharge after 24 or 48 h: a longitudinal randomized prospective study. BMC Urol 2023; 23:149. [PMID: 37735383 PMCID: PMC10512494 DOI: 10.1186/s12894-023-01318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND There is a tendency of prompted global health systems to reduce the length of hospital stay without compromising patient safety or satisfaction. We evaluated the safety and viability of early discharge in patients undergoing minimally invasive radical prostatectomy (MIRP), as well as patient satisfaction with this strategy. METHODS This longitudinal prospective study included 72 patients who underwent MIRP for prostate cancer. Three groups were performed according to the day of hospital discharge following surgery: same day (G1), first day after (G2), and second day after (G3). Satisfaction, adverse events, and readmission were analyzed for each group. Associations between clinicopathologic variables and same-day discharge were analyzed by comparing data between G1 patients who did and did not achieve same-day discharge. RESULTS 16.7% of patients were not discharged according to randomization (10 randomized to G1). 80% of G1 patients who did not achieve same-day discharge had Gleason scores of 3 + 4 or 4 + 3, which were observed in 35.7% of patients discharged on the same day (P < 0.05). Average prostate weight was significantly lower in patients who achieved same-day discharge than in those who did not (P < 0.01). Univariable logistic regression points to Gleason scores of 3 + 4 or 4 + 3 as the main factors associated with unsuccessful same-day discharge (P < 0.05). There were no significant differences in satisfaction scores. CONCLUSIONS Same-day discharge was both safe and feasible and does not appear to affect satisfaction in a subset of patients with prostate cancer. Surgeons should consider the Gleason score when determining whether same-day discharge is appropriate.
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Affiliation(s)
| | - Roberto Dias Machado
- Department of Urology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, S. Paulo, CEP 14784 400, Brazil
| | | | | | - Lucas Tadeu Bidinotto
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil
- School of Medicine, Department of Pathology, UNESP - Univ. Estadual Paulista, Botucatu, São Paulo, Brazil
- Barretos School of Health Sciences, Dr. Paulo Prata - FACISB, Barretos, Brazil
| | | | - Ricardo Dos Reis
- Department of Gynecology, Barretos Cancer Hospital, Barretos, Brazil
| | - Daniele Natália Pacharone Bertolini Bidinotto
- Department of Urology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, S. Paulo, CEP 14784 400, Brazil.
- Barretos School of Health Sciences, Dr. Paulo Prata - FACISB, Barretos, Brazil.
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3
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Lauscher J, Beyer K, Hellinger A, Croner RS, Ridwelski K, Krautz C, Lim C, Coplan PM, Kurepkat M, Ribaric G. Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study. BMJ Open 2023; 13:e070053. [PMID: 36972968 PMCID: PMC10069574 DOI: 10.1136/bmjopen-2022-070053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION With growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal surgery, but their misuse or malfunction encompass a unique risk of postoperative complications. The Digital Device Briefing Tool (DDBT) is a digital cognitive aid developed to enhance safe use of the Ethicon circular stapling device during colorectal resection. The purpose of this study is to evaluate how a digital operative workflow, including DDBT, compared with routine surgical care, affects morbidity and mortality in patients undergoing left-sided colorectal resection with primary stapled colorectal anastomosis for colorectal cancer or benign disease. METHODS AND ANALYSIS A multicentre, prospective cohort study will be conducted at five certified academic colorectal centres in Germany. It compares a non-digital with a Johnson & Johnson digital solution (Surgical Process Institute Deutschland (SPI))-guided operative workflow in patients undergoing left hemicolectomy, sigmoidectomy, anterior rectal resection and Hartmann reversal procedure. The sample size is set at 528 cases in total, divided into 3 groups (a non-digital and two SPI-guided workflow cohorts, with and without DDBT) in a ratio of 1:1:1, with 176 patients each. The primary endpoint is a composite outcome comprising the overall rate of surgical complications, including death, during hospitalisation and within the first 30 days after colorectal resection. Secondary endpoints include operating time, length of hospital stay and 30-day hospital readmission rate. ETHICS AND DISSEMINATION This study will be performed in line with the Declaration of Helsinki. The ethics committee of the Charité-University Medicine Berlin, Germany, approved the study (No: 22-0277-EA2/060/22). Study Investigators will obtain written informed consent from each patient before a patient may participate in this study. The study results will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00029682.
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Affiliation(s)
- Johannes Lauscher
- Department of General and Visceral Surgery, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Achim Hellinger
- Department of General, Visceral, Endocrine and Oncologic Surgery, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
| | - Karsten Ridwelski
- An-Institute of Quality Assurance in Operative Medicine, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
- Clinic for General and Visceral Surgery, Klinikum Magdeburg gGmbH, Magdeburg, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christine Lim
- Johnson & Johnson MedTech Medical Safety, Johnson & Johnson World Headquarters US, New Brunswick, New Jersey, USA
| | - Paul M Coplan
- Department of Epidemiology, Office of the Chief Medical Officer, Johnson & Johnson World Headquarters US, New Brunswick, New Jersey, USA
- Adjunct, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marc Kurepkat
- CSG - Clinische Studien Gesellschaft mbH, Berlin, Germany
| | - Goran Ribaric
- Johnson & Johnson Institute Hamburg, Johnson & Johnson Medical GmbH, Norderstedt, Germany
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Feasibility and Safety of Ambulatory Surgery as the Next Management Paradigm in Colorectal Resection Surgery. Ann Surg 2022; 276:562-569. [PMID: 35758475 DOI: 10.1097/sla.0000000000005561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis. We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis. METHODS Between October 2020-October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria (no major comorbidity (ASA<4), not on therapeutic anticoagulation, compliant patient/family) were counseled preoperatively for ambulatory surgery (discharge <24 h post-surgery). Complicated surgery (ileoanal pouch, enterocutaneous fistula repair, re-operative pelvic surgery, multiple resections) and/or ostomy creation (loop/end ileostomy, Hartmann's, abdominoperineal resection) were exclusions. Discharge was at 6-8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals and blood-work) were met and patients were willing, or was postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care was preferred by patient. Patients discharged <24 hours postop (AmbC) were compared to those staying on as inpatients admitted (InpC) and also to a comparable historical (October 2019-October 2020) group when ambulatory surgery was not offered (HistC). RESULTS Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged <24 hours postoperatively (7 (24%) patients at 8 h). Of these 29 AmbC patients, 4 were readmitted <30 days (ileus:1, rectal bleeding:2, nausea/vomiting: 1), 1 readmission was on first post-discharge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, gender, race, body mass index (BMI) and comorbidity (table). InpC had greater estimated blood loss (109 vs. 34 mL, P<0.001) while length of stay (LOS) was expectedly significantly longer (109 vs. 17 h, P<0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus and surgical site infection (SSI). Mean LOS for HistC was 83 hours. AmbC and HistC had similar age, gender, race, BMI and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus and SSI were also similar for AmbC and HistC. CONCLUSIONS With careful patient selection, preoperative education, perioperative management and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Refinements in inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications for patient experience, care-giver workload and healthcare finances.
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Meillat H, Serenon V, Brun C, de Chaisemartin C, Faucher M, Lelong B. Impact of fast-track care program in laparoscopic rectal cancer surgery: a cohort-comparative study. Surg Endosc 2022; 36:4712-4720. [DOI: 10.1007/s00464-021-08811-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 10/17/2021] [Indexed: 11/29/2022]
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Elective colectomy financial and opportunity cost analysis: diagnosis, case type, diversion, and complications. Eur Surg 2021. [DOI: 10.1007/s10353-021-00716-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hill AG. Enhanced recovery after surgery: tips and tricks for success. ANZ J Surg 2021; 91:228-229. [PMID: 33740302 DOI: 10.1111/ans.16533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew G Hill
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand
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8
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Mallard SR, Clifford KA, Park R, Cousins K, Patton A, Woodfield JC, Thompson-Fawcett M. Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study. BMC Surg 2021; 21:132. [PMID: 33726715 PMCID: PMC7962301 DOI: 10.1186/s12893-021-01149-8] [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: 11/02/2020] [Accepted: 03/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. Methods Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). Results Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. Conclusions Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team’s expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.
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Affiliation(s)
- Simonette R Mallard
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Kari A Clifford
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - R Park
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | | | - Kim Cousins
- Department of Preventive and Social Medicine, Dunedin Medical Campus, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ann Patton
- Dunedin Public Hospital, Dunedin, New Zealand
| | - John C Woodfield
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Mark Thompson-Fawcett
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
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9
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Veziant J, Poirot K, Mulliez A, Pereira B, Slim K. Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections. Langenbecks Arch Surg 2020; 405:1155-1162. [PMID: 33057822 DOI: 10.1007/s00423-020-02001-y] [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: 07/03/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery. METHODS This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS. RESULTS A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R). CONCLUSION ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.
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Affiliation(s)
- J Veziant
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France.
| | - K Poirot
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France
| | - A Mulliez
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), University Hospital, Clermont Ferrand, France
| | - B Pereira
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), University Hospital, Clermont Ferrand, France
| | - K Slim
- Department of Digestive and Hepatobiliary Surgery, University Hospital, Clermont-Ferrand, France
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Hung LY, Benlice C, Jia X, Steele SR, Valente MA, Holubar SD, Gorgun E. Outcomes after Early versus Delayed Urinary Bladder Catheter Removal after Proctectomy for Benign and Malignant Disease in 2,429 Patients: An Observational Cohort Study. Surg Infect (Larchmt) 2020; 22:310-317. [PMID: 32721201 DOI: 10.1089/sur.2020.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: There currently is no standard practice for optimal urinary catheter removal after rectal resection (proctectomy). Delayed removal may increase urinary tract infection risk, an important hospital quality metric. This study aimed to assess the effect of catheter duration on urinary tract infection rate. We hypothesized that early removal would be associated with fewer infections. Methods: We performed a retrospective review of patients who underwent proctectomy from January 2007 to December 2017 with urinary catheter placement in our colorectal surgery department. The main outcome measures were urinary tract infection, post-operative urinary retention, and length of stay. Patients were divided into early (post-operative day one or two) and late (day three or later) removal groups. Results: A series of 2,429 patients were included; 1,176 in the early and 1,253 in the late group. The early group had a shorter median length of stay (5.26 versus 7 days). The urinary tract infection (n = 77) multivariable logistic regression model showed no association between timing of removal and infection; however, females had more infections (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.65-4.41). The post-operative urinary retention model (n = 280) showed no association between the timing of removal and retention; however, patients who underwent pre-operative radiation (OR 1.55; 95% CI 1.15-2.09) or total proctocolectomy (OR 1.74; 95% CI 1.21-2.49) or were male (OR 1.35; 95% CI 1.02-1.78) were more likely to have retention. When analyzed by specific removal day, each one-day delay in removal increased the odds of infection by 21% (OR 1.21; 95% CI 1.09-1.35] and decreased the odds of retention by 12% (OR 0.88; 95% CI 0.80-0.97] with a cross-over at 9 days. Patients who experienced retention were not more likely to have infection. Conclusion: Early urinary catheter removal after proctectomy was associated with a lower urinary tract infection rate and a shorter hospital stay.
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Affiliation(s)
- Laurie Y Hung
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cigdem Benlice
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xue Jia
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Valente
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
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Jaloun HE, Lee IK, Kim MK, Sung NY, Turkistani SAA, Park SM, Won DY, Hong SH, Kye BH, Lee YS, Jeon HM. Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery. Ann Coloproctol 2020; 36:264-272. [PMID: 32674557 PMCID: PMC7508488 DOI: 10.3393/ac.2020.03.25] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/25/2020] [Indexed: 01/25/2023] Open
Abstract
Purpose Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. Methods Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. Results The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). Conclusion ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.
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Affiliation(s)
- Heba Essam Jaloun
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ki Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Na Young Sung
- Cancer Information & Education Branch, National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Suhail Abdullah Al Turkistani
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Min Park
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Youn Won
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae Myung Jeon
- Department of General Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective 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.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven 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 methodsComparative 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.FindingsA 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.LimitationsStudies 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.ConclusionsEnhanced 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 workFurther 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 registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Tang J, Liu X, Ma T, Lv X, Jiang W, Zhang J, Lu C, Chen H, Li W, Li H, Xie H, Du C, Geng Q, Feng J, Tang W. Application of enhanced recovery after surgery during the perioperative period in infants with Hirschsprung's disease - A multi-center randomized clinical trial. Clin Nutr 2019; 39:2062-2069. [PMID: 31676258 DOI: 10.1016/j.clnu.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND & AIMS Various enhanced recovery after surgery (ERAS) guidelines have been established for several kinds of adult surgeries. While the guidelines for pediatric surgeries remained to be explored. The aim of the study was to prospectively evaluate the safety and efficacy of an ERAS protocol for Hirschsprung's disease (HSCR) infants undergoing pull-through procedures. METHODS An infant-specific ERAS protocol was developed and implemented at multiple centers from June 1, 2016 to December 31, 2017. The study included 145 consecutive patients who underwent pull-through surgery for HSCR in three Children's hospitals. Patients were primarily divided into three groups based on the clinical classification and surgical methods. Group I included patients with the short segment type who received transanal endorectal pull-through (TEPT) surgery. Group II comprised of patients with the classical type and long segment type who received laparoscopic-assisted pull-through (LAPT) surgery. Group III involved patients with the long segment type (who had received ileostomy or colostomy during the neonatal period) and total colonic aganglionosis who received open pull-through (OPPT) surgery. Patients in the three groups mentioned above were randomly and equally assigned into the ERAS group and traditional (TRAD) group with random number table row randomization. The primary outcome was the length of postoperative hospital stay (LOS). Secondary outcomes of interest included white blood cell (WBC) and C-reactive protein (CRP) on postoperative day 1 (POD 1), the blood glucose at the time of anesthesia and 24 h after surgery, time to first defecation, time to regular diet, plasma markers of nutrition status on POD 5, plasma natrium on POD 5, the mean intraoperative fluid volume, time to discontinuation of intravenous infusion, incidence of postoperative complications, re-admission within 30 days, hospitalization costs, parental satisfaction, and growth from admission to 6 months after surgery. RESULTS 73 and 75 patients were assigned to the TRAD and ERAS groups, respectively. There were no significant differences in demographic data. The LOS decreased from 9.5 days in the TRAD group to 7.9 days (P < 0.001) in the ERAS group. WBC count on POD 1 showed no significant difference between the two groups. CRP on POD 1 in the ERAS group was significantly lower (P < 0.001). In the ERAS group, the blood glucose was higher at anesthesia compared to the TRAD group (P < 0.001). On the contrary, the blood glucose at 24 h after surgery was significantly lower in the ERAS group (P < 0.001). Intraoperative fluid volume was lower in the EARS group (P < 0.001). ERAS could also reduce the time to first defecation (P < 0.001), discontinuation of intravenous infusion (P < 0.001) and regular diet (P < 0.001). In the ERAS group, the concentrations of prealbumin and retinol conjugated protein on POD 5 were higher than those in the TRAD group (P < 0.001, P < 0.001, respectively). The plasma natrium had no difference in the two groups on POD 5 (P > 0.05). The rate of complications (P > 0.05) and 30-day re-admission (P > 0.05) were not significantly different between the two groups. Hospitalization costs were also reduced (P < 0.001). ERAS group has a higher parental satisfaction rate, although there was no statistical difference (96% vs 89%). There was no difference in growth between the ERAS and the TRAD groups from admission to 6 months after the surgery (weight for age z score: P > 0.05, weight for length z score: P > 0.05). We also found that the shortening of LOS by the application of ERAS protocol was more obvious in the OPPT group (-2.5 ± 1.0) than that in the TEPT (-1.9 ± 1.3) and LAPT (-1.3 ± 0.4) groups. CONCLUSIONS Implementation of the ERAS protocol in infants undergoing HSCR pull-through operations is safe and efficient. The ERAS protocol is worthy of recommendation. TRIAL REGISTRATION Clinical Trials.gov identifier: NCT02776176.
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Affiliation(s)
- Jie Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Xiang Liu
- Department of Pediatric Surgery, Anhui Provincial Children's Hospital, Hefei 230000, China
| | - Tongshen Ma
- Department of Pediatric Surgery, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Xiaofeng Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Jie Zhang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Changgui Lu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Huan Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hongxing Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Chunxia Du
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China.
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Gong R, Hu Q, Liu D, Zu J, Wu Y, Xia Z. Enhanced recovery after surgery versus traditional care in total pelvic floor reconstruction surgery with transvaginal mesh. Int J Gynaecol Obstet 2019; 148:107-112. [PMID: 31591718 DOI: 10.1002/ijgo.12991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 08/04/2019] [Accepted: 10/04/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the impact of enhanced recovery after surgery (ERAS) on perioperative outcomes after total pelvic floor reconstruction surgery with transvaginal mesh. METHODS A single-center, retrospective observational cohort study involved 177 patients who underwent total pelvic floor reconstruction surgery with transvaginal mesh between August 2015 and November 2017. Eighty-five patients treated according to a traditional protocol formed the control group and 92 patients treated using the ERAS pathway were assigned to the ERAS group. Registered outcomes included demographic characteristics, intraoperative and postoperative data (first assisted walking time, first intestinal exhaust time, length of stay, hospital costs), and complications. RESULTS The first assisted walking time (40.6 ± 1.48 vs 23.56 ± 3.26 hours, P<0.001) and the first intestinal exhaust time (27.65 ± 11.63 vs 18.65 ± 10.68 hours, P<0.001) were earlier in the ERAS group. The implementation of the ERAS pathway was associated with shorter length of stay (121.35 vs 70.25 hours, P<0.001) and lower hospital costs (46 838.65 ± 2584.08 vs 42 793.57 ± 2560.3 RMB, P<0.001). There was no difference in surgical outcomes or postoperative complications between the two groups. CONCLUSION ERAS is safe, economical, and reliable after total pelvic floor reconstruction surgery and promotes perioperative recovery without increasing complication rates.
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Affiliation(s)
- Runqi Gong
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Qing Hu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Dan Liu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Jianyu Zu
- Anesthesia Department, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Ying Wu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Zhijun Xia
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
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Surve A, Cottam D, Zaveri H, Cottam A, Belnap L, Richards C, Medlin W, Duncan T, Tuggle K, Zorak A, Umbach T, Apel M, Billing P, Billing J, Landerholm R, Stewart K, Kaufman J, Harris E, Williams M, Hart C, Johnson W, Lee C, Lee C, DeBarros J, Orris M, Schniederjan B, Neichoy B, Dhorepatil A, Cottam S, Horsley B. Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies. Surg Obes Relat Dis 2018; 14:1442-1447. [DOI: 10.1016/j.soard.2018.05.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022]
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Indocyanine green fluorescence angiography: a new ERAS item. Updates Surg 2018; 70:427-432. [DOI: 10.1007/s13304-018-0590-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/20/2018] [Indexed: 12/22/2022]
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Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29609882 PMCID: PMC9391696 DOI: 10.1016/j.bjane.2018.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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Ripollés-Melchor J, Fuenmayor-Varela MLD, Camargo SC, Fernández PJ, Barrio ÁCD, Martínez-Hurtado E, Casans-Francés R, Abad-Gurumeta A, Ramírez-Rodríguez JM, Calvo-Vecino JM. [Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]. Rev Bras Anestesiol 2018; 68:358-368. [PMID: 29609882 DOI: 10.1016/j.bjan.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/21/2017] [Accepted: 01/03/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. METHODS Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. RESULTS There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. CONCLUSIONS The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.
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Affiliation(s)
- Javier Ripollés-Melchor
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha.
| | | | - Susana Criado Camargo
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | - Pablo Jerez Fernández
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Madri, Espanha
| | | | - Eugenio Martínez-Hurtado
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - Rubén Casans-Francés
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Anestesia, Zaragoza, Espanha
| | - Alfredo Abad-Gurumeta
- Universidad Complutense de Madrid, Madri, Espanha; Hospital Universitario Infanta Leonor, Departamento de Anestesia, Madri, Espanha; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha
| | - José Manuel Ramírez-Rodríguez
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Hospital Clínico Universitario Lozano Blesa, Departamento de Cirugía, Zaragoza, Espanha
| | - José María Calvo-Vecino
- Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Espanha; Universidad de Salamanca, Salamanca, Espanha; Complejo Hospitalario de Salamanca, Departamento de Anestesia, Salamanca, Espanha
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Garfinkle R, Boutros M, Ghitulescu G, Vasilevsky CA, Charlebois P, Liberman S, Stein B, Feldman LS, Lee L. Clinical and Economic Impact of an Enhanced Recovery Pathway for Open and Laparoscopic Rectal Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:811-818. [PMID: 29451415 DOI: 10.1089/lap.2017.0677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The short-term benefits of laparoscopy for rectal surgery are equivocal. The objective of this study was to determine the clinical and economic impact of an enhanced recovery pathway (ERP) for laparoscopic and open rectal surgery. MATERIALS AND METHODS All patients who underwent elective rectal resection with primary anastomosis between January 2009 and March 2012 at two tertiary-care, university-affiliated institutions were identified. Patients who met inclusion criteria were divided into four groups, according to surgical approach (laparoscopic [lap] or open) and perioperative management (ERP or conventional care [CC]). Length of stay (LOS), postoperative complications, and hospital costs were compared. RESULTS A total of 381 patients were included in the analysis (201 open-CC, 34 lap-CC, 38 open-ERP, and 108 lap-ERP). Patients were mostly similar at baseline. ERPs significantly reduced median LOS after both open cases (open-CC 10 days versus open-ERP 7.5 days, P = .003) and laparoscopic cases (lap-CC 5 days versus lap-ERP 4.5 days, P = .046). ERPs also reduced variability in LOS compared with CC. There was no difference in postoperative complications with the use of ERPs (open-CC 51% versus open-ERP 50%, P = .419; lap-CC 32% versus lap-ERP 36%, P = .689). On multivariate analysis, both ERP (-3.6 days [95% confidence interval, CI -6.0 to -1.3]) and laparoscopy (-3.6 days [95% CI -5.9 to -1.0]) were independently associated with decreased LOS. Overall costs were only lower when lap-ERP was compared with open-CC (mean difference -2420 CAN$ [95% CI -5628 to -786]). CONCLUSIONS ERPs reduced LOS after rectal resections, and the combination of laparoscopy and ERPs significantly reduced overall costs compared to when neither strategy was used.
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Affiliation(s)
- Richard Garfinkle
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Marylise Boutros
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Gabriela Ghitulescu
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Carol-Ann Vasilevsky
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Patrick Charlebois
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Sender Liberman
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Barry Stein
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Liane S Feldman
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Lawrence Lee
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
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Nakahara A, Ulrich ND, Gala R. Opiate Prescribing Practices in the Postpartum Unit. Ochsner J 2018; 18:36-41. [PMID: 29559867 PMCID: PMC5855419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Louisiana is significantly impacted by the opioid epidemic. In preparation for a quality improvement project aimed at decreasing postpartum narcotics prescriptions, we evaluated routine prescribing practices on a postpartum unit and the number of patient-initiated encounters for postpartum pain. METHODS We conducted a retrospective medical record review of all vaginal deliveries occurring at Ochsner Baptist Medical Center in New Orleans, LA in December 2016 and January 2017. We collected patient demographics, inpatient and outpatient pain medications, and the number of postpartum pain-related encounters prior to the scheduled postpartum visit. We evaluated the cohort for inpatient medication usage and for postpartum encounters for pain. RESULTS After exclusions, 187 of 369 patients were included in the analysis: 78 patients had no perineal laceration, 40 had a first-degree laceration, and 69 had a second-degree laceration. The no-laceration (P=0.007) and second-degree laceration (P=0.011) groups had a significantly higher mean morphine milligram equivalent (MME) per patient during hospitalization than the first-degree group. Sixty-four patients were primiparous, and 123 were multiparous. Parity decreased as the severity of the laceration increased. Multiparous patients had a higher mean MME than primiparous patients (34.5 vs 30.0, respectively) during hospitalization, but the difference was not significant. In the no-laceration group, multiparous patients used significantly more narcotics during hospitalization (mean 41.4 MME) than primiparous patients (mean 22.5 MME) (P=0.029). A total of 3,635 narcotic pills were prescribed for our cohort at discharge, an average of 19.4 pills per patient. Overall, the mean number of postpartum encounters for pain was 0.19 per patient, with no difference between groups. CONCLUSION Despite a high number of outpatient narcotics prescriptions, approximately 1 in 5 patients initiated an encounter to address pain after vaginal delivery. Parity may play a role in postpartum inpatient narcotic usage, possibly because multiparous patients have had prior exposure to narcotics use in postpartum care.
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Affiliation(s)
- Angela Nakahara
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Nicole D. Ulrich
- Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, LA
| | - Rajiv Gala
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, LA
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Martin AN, Berry PS, Friel CM, Hedrick TL. Impact of minimally invasive surgery on short-term outcomes after rectal resection for neoplasm within the setting of an enhanced recovery program. Surg Endosc 2017; 32:2517-2524. [PMID: 29101566 DOI: 10.1007/s00464-017-5956-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/21/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) for rectal cancer has increased in recent years. Enhanced recovery (ER) protocols are associated with improved outcomes, such as decreased length of stay (LOS). We examined the impact of MIS and ER protocols on outcomes after rectal resection for neoplasm. METHODS A retrospective analysis was performed for patients undergoing elective open (OS) or MIS rectal resection for neoplasm from 2010 to 2015 at a single institution. MIS was defined as any laparoscopic or robotic procedure. An ER protocol was implemented in 8/2013. Regression models were used to estimate outcomes including LOS, 30-day morbidity, readmission, and hospital costs. RESULTS Among 325 patients, 252 (77.5%) underwent OS; 73 (22.5%) underwent MIS rectal resection. Prior to ER implementation, only 6.1% underwent MIS, compared to 23.1 and 54.4% in the 2 years following ER implementation (p < 0.001). Prior to ER implementation, median LOS was 7 days (n = 181) with 23.8% 30-day morbidity. Following ER implementation, median LOS was 4 days (n = 144); patients receiving OS had median LOS of 5.5 days (n = 82) and 30-day morbidity of 19.5%. ER patients receiving MIS had median LOS of 3 days (n = 62) and 30-day morbidity of 14.5%. Univariate regression demonstrated that MIS patients on ER protocol were more likely to have a shortened LOS (< 6 days) compared to OS patients on non-ER protocol (both p < 0.001). CONCLUSIONS The combination of MIS and ER protocol is significantly associated with reduced LOS for patients undergoing rectal resection for neoplasm. Further research is needed to determine which patients are best suited to MIS from an oncologic standpoint.
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Affiliation(s)
- Allison N Martin
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Puja Shah Berry
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Charles M Friel
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA
| | - Traci L Hedrick
- Department of Surgery, Section of Colon and Rectal Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.
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Oliveira RA, Guatura GMGBDS, Peniche ADCG, Costa ALS, Poveda VDB. An Integrative Review of Postoperative Accelerated Recovery Protocols. AORN J 2017; 106:324-330.e5. [PMID: 28958318 DOI: 10.1016/j.aorn.2017.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/02/2017] [Accepted: 08/04/2017] [Indexed: 02/07/2023]
Abstract
We undertook an integrative literature review of articles pertaining to perioperative nursing care provided to patients using postoperative accelerated recovery protocols. To select the articles, we searched the MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature, and LiteraturaLatino-Americana e do Caribe em Ciências da Saúde databases. We identified 329 studies, 13 of which met our inclusion criteria and described perioperative nursing care activities. Nursing activities noted in these articles were hypothermia prevention and maintenance of normothermia, restriction of IV fluids, assessment of vital signs, management of symptoms and pain, support of early ambulation, care for tubes and drains, oral administration of carbohydrate-rich foods, assessment of ability to tolerate diet, and encouragement to resume activities of daily living. There was a lack of research on this topic by nursing professionals; additional research by nursing professionals is needed regarding nurses' roles in providing this care.
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Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs or hip and knee replacements have had a significant effect on streamlining patient care with shorter stays, no increase in complications, and improved outcomes including reduced mortality. PURPOSE To compare outcomes following the introduction of an ERAS program for hip and knee replacements developed at our institution with a historical cohort of patients. METHODS ERAS protocols were developed at our institution for patients undergoing hip and knee joint replacements. Key aspects were changes in preadmission, a new education session, improved management of perioperative anemia, standardized anesthetic guidelines, day of surgery mobilization, and improved discharge planning. The results of the first 18 months (528 consecutive patients) were compared with those of a historical cohort of 507 patients from the 18 months prior to their introduction. RESULTS In the ERAS group, the mean age was 68.3 years for patients who underwent hip replacement and 70.4 years for patients who underwent knee replacement. Thirty-two percent of patients were ASA (American Society of Anesthesiologists) Grades III and IV. The average preoperative Oxford score was 11. The average length of stay (ALOS) fell from 5.6 to 4.3 days for patients who underwent hip replacement and from 5.7 to 4.8 days for patients who underwent knee replacement (p < .001). Ninety-six percent of patients were discharged home. The 30-day readmission rate increased from 3.2% to 5.5% (p = .065). Six-month Oxford knee scores were higher in the ERAS group (39.8 vs. 36.3, p = .03). There was no increase in mortality or early revision rate. CONCLUSIONS Substantial reductions in ALOS can be gained with the introduction of ERAS protocols, with high patient satisfaction and no increase in complications in a consecutive unselected group of public hospital patients. This requires a multidisciplinary approach and a strong clinical input.
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Pereira NDC, Turrini RNT, Poveda VDB. Perioperative fasting time among cancer patients submitted to gastrointestinal surgeries. Rev Esc Enferm USP 2017; 51:e03228. [PMID: 28562746 DOI: 10.1590/s1980-220x2016036203228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/03/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To identify the length of perioperative fasting among patients submitted to gastrointestinal cancer surgeries. METHOD Retrospective cohort study, developed by consulting the medical records of 128 patients submitted to gastrointestinal cancer surgeries. RESULTS The mean of total length of fasting was 107.6 hours. The total length of fasting was significantly associated with the number of symptoms presented before (p=0.000) and after the surgery (p=0.007), the length of hospital stay (p=0.000), blood transfusion (p=0.013), nasogastric tube (p=0.001) and nasojejunal tube (p=0,003), postoperative admission at ICU (p=0.002), postoperative death (p=0.000) and length of preoperative fasting (p=0.000). CONCLUSION The length of fasting is associated with complications that affect the quality of the patients' postoperative recovery and nurses' work. The nursing team should be alert to this aspect and being responsible for overseeing the patients' interest, should not permit the unnecessary extension of fasting. OBJETIVO Identificar la duración del ayuno perioperatorio entre los pacientes sometidos a cirugías de cáncer gastrointestinal. MÉTODO Estudio de cohorte retrospectivo, por consulta de los registros médicos de 128 pacientes sometidos a cirugías de cáncer gastrointestinal. RESULTADOS La media de la duración total del ayuno fue de 107,6 horas. La duración total del ayuno se asoció significativamente con el número de síntomas presentados antes (p=0,000) y después de la cirugía (p=0,007), la duración de la estancia hospitalaria (p=0,000), transfusión de sangre (p=0,013),tubo nasogástrico (P=0,003), ingreso postoperatorio en la UCI (p=0,002), muerte postoperatoria (p=0,000) y duración del ayuno preoperatorio (p=0,000). CONCLUSIÓN La duración del ayuno se asocia con complicaciones que afectan la calidad de la recuperación postoperatoria de los pacientes y el trabajo de enfermería. El equipo de enfermería debe estar alerta en relación a este aspecto y ser responsable de supervisar el interés de los pacientes, no permitiendo la extensión innecesaria del ayuno.
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Affiliation(s)
| | - Ruth Natalia Teresa Turrini
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
| | - Vanessa de Brito Poveda
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
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Jakobsson J, Idvall E, Kumlien C. The lived experience of recovery during the first 6 months after colorectal cancer surgery. J Clin Nurs 2017; 26:4498-4505. [DOI: 10.1111/jocn.13780] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Jenny Jakobsson
- Department of Care Science; Faculty of Health and Science; Malmö University; Malmö Sweden
- Department of Surgery; Skåne University Hospital; Malmö Sweden
| | - Ewa Idvall
- Department of Care Science; Faculty of Health and Science; Malmö University; Malmö Sweden
| | - Christine Kumlien
- Department of Care Science; Faculty of Health and Science; Malmö University; Malmö Sweden
- Department of Vascular Diseases; Skåne University hospital; Malmö Sweden
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26
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Brescia A, Tomassini F, Berardi G, Sebastiani C, Pezzatini M, Dall'Oglio A, Laracca GG, Apponi F, Gasparrini M. Development of an enhanced recovery after surgery (ERAS) protocol in laparoscopic colorectal surgery: results of the first 120 consecutive cases from a university hospital. Updates Surg 2017; 69:359-365. [PMID: 28332129 DOI: 10.1007/s13304-017-0432-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/11/2017] [Indexed: 12/20/2022]
Abstract
The ERAS® represents a dynamic culmination of upon perioperative care elements, successfully applied to different surgical specialties with shorter hospital stay and lower morbidity rates. The aim of this study is to describe the introduction of the ERAS protocol in colorectal surgery in our hospital analysing our first series. Between September 2014 and June 2016, 120 patients suffering from colorectal diseases were included in the study. Laparoscopic approach was used in all patients if not contraindicated. Patients were discharged when adequate mobilization, canalization, and pain control were obtained. Analysed outcomes were: length of hospital stay, readmission rate, perioperative morbidity, and mortality. Malignant lesions were the most common indication (84.2%; 101/120). Laparoscopic approach was performed in the 95.8% of cases (115/120) with a conversion rate of 4.4% (5/115). Surgical procedures performed were: 36 rectal resections (30%), 36 left colonic resections (30%), 42 right hemicolectomy (35%), and 6 Miles (5%). The median hospital stay was of 4 (3-34) days in the whole series with a morbidity rate of 10% (12/120); four patients experienced Clavien-Dindo ≥ IIIa complications; and only one anastomotic leak was observed. No 30-day readmission and no perioperative mortality were recorded. At the univariate analysis, the presence of complications was the only predictive factor for prolonged hospital stay (p < 0.001). In our experience, implementation of ERAS protocol for colorectal surgery allows a significant reduction of hospital stay improving perioperative management and postoperative outcomes.
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Affiliation(s)
- Antonio Brescia
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Federico Tomassini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy.
| | - Giammauro Berardi
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Carola Sebastiani
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Massimo Pezzatini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Anna Dall'Oglio
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Giovanni Guglielmo Laracca
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Fabrizio Apponi
- Department of Anaesthesiology, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Marcello Gasparrini
- Department of General Surgery, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy
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Tevis SE, Kennedy GD. Postoperative Complications: Looking Forward to a Safer Future. Clin Colon Rectal Surg 2016; 29:246-52. [PMID: 27582650 DOI: 10.1055/s-0036-1584501] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colorectal surgery patients frequently suffer from postoperative complications. Patients with complications have been shown to be at higher risk for mortality, poor oncologic outcomes, additional complications, and worse quality of life. Complications are increasingly recognized as markers of quality of care with more use of risk-adjusted national surgical databases and increasing transparency in health care. Quality improvement work in colorectal surgery has identified methods to decrease complication rates and improve outcomes in this patient population. Future work will continue to identify best practices and standardized ways to measure quality of care.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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Is expedited early discharge following elective surgery for colorectal cancer safe? An analysis of short-term outcomes. Surg Endosc 2015; 30:3904-9. [DOI: 10.1007/s00464-015-4696-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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Day RW, Fielder S, Calhoun J, Kehlet H, Gottumukkala V, Aloia TA. Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement. Br J Surg 2015; 102:1594-1602. [PMID: 26364714 DOI: 10.1002/bjs.9918] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/03/2015] [Accepted: 07/16/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery. METHODS PubMed, Embase and Cochrane Central Register databases were searched for current colorectal ER manuscripts. Each publication was assessed for the number of ER elements, whether the element was explained sufficiently so that it could be transferred to clinical practice, and compliance with the ER element. RESULTS Some 50 publications met the reporting criteria for inclusion. A total of 22 ER elements were described. The median number of elements included in each publication was 9, and the median number of included patients was 130. The elements most commonly included in ER pathways were early postoperative diet advancement (49, 98 per cent) and early mobilization (47, 94 per cent). Early diet advancement was sufficiently explained in 43 (86 per cent) of the 50 publications, but only 22 (45 per cent) of 49 listing the variable reported compliance. The explanation for early mobilization was satisfactory in 41 (82 per cent) of the 50 publications, although only 14 (30 per cent) of 47 listing the variable reported compliance. Other ER elements had similar rates of explanation and compliance. The most frequently analysed outcome measures were morbidity (49, 98 per cent), length of stay (47, 94 per cent) and mortality (45, 90 per cent). CONCLUSION The current standard of reporting is frequently incomplete. To transfer knowledge and facilitate implementation of pathways that demonstrate improvements in perioperative care and recovery, a consistent structured reporting platform is needed.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Sharon Fielder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - John Calhoun
- Institute for Cancer Care Innovation at The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University, Denmark
| | - Vijaya Gottumukkala
- Department of Anaesthesia, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, Texas 77030
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Gotlib Conn L, McKenzie M, Pearsall EA, McLeod RS. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences. Implement Sci 2015; 10:99. [PMID: 26183086 PMCID: PMC4504167 DOI: 10.1186/s13012-015-0289-y] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change. METHODS A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit. RESULTS Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support. CONCLUSIONS Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.
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Affiliation(s)
- Lesley Gotlib Conn
- Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Room K3W-28, Toronto, ON, M4N 3M5, Canada.
| | - Marg McKenzie
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Emily A Pearsall
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Robin S McLeod
- Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 1P5, Canada.
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Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Dis Colon Rectum 2014; 57:557-63. [PMID: 24819094 DOI: 10.1097/dcr.0000000000000101] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Enhanced recovery pathways have been shown to decrease the length of hospital stay in patients undergoing colorectal surgery. Few reports have studied patients undergoing minimally invasive surgery for rectal cancer. OBJECTIVE Our aim was to review our experience in minimally invasive rectal cancer surgery. We report short-term outcomes and evaluate the potential advantages of the enhanced recovery protocol compared with our less intensive conventional pathway. DESIGN This is a consecutive retrospective study of all minimally invasive rectal cancers treated from February 2005 to December 2011. Multivariable logistic regression models were constructed to identify factors contributing to a short length of stay. SETTINGS This study was performed at Mayo Clinic, Rochester, Minnesota, between 2005 and 2011. PATIENTS A total of 346 patients were retrospectively reviewed. Seventy-eight patients were managed under the enhanced recovery pathway. Patients underwent either laparoscopic-, robotic-, or hand-assisted laparoscopic surgery for rectal cancer. INTERVENTIONS All patients followed either a standardized conventional pathway or an enhanced recovery pathway for perioperative care. MAIN OUTCOME MEASURES The primary outcome was the length of stay. Secondary outcomes were postoperative complications and 30-day readmissions. RESULTS Hospital stay was significantly decreased for patients who underwent minimally invasive surgery for rectal cancer and were managed with an enhanced recovery protocol, 4.1 days, vs 6.1 days for the conventional pathway (95% CI, -2.9 to -1.2 days; p < 0.0001). Rates of complications were similar between the 2 groups. Factors associated with shorter length of stay included the enhanced recovery protocol and laparoscopic or robotic surgery compared with hand-assisted laparoscopic surgery. LIMITATIONS This was a retrospective study at a single institution. Additional limitations include the comparison with historical controls and the potential for selection bias. CONCLUSION The enhanced recovery pathway is associated with a significantly decreased length of hospital stay after minimally invasive surgery for rectal cancer in this series. Decreased hospital stay was achieved without affecting short-term outcomes.
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Huebner M, Hübner M, Cima RR, Larson DW. Timing of complications and length of stay after rectal cancer surgery. J Am Coll Surg 2014; 218:914-9. [PMID: 24661855 DOI: 10.1016/j.jamcollsurg.2013.12.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 12/23/2013] [Accepted: 12/30/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway. STUDY DESIGN This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery. RESULTS A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73-0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09-3.78; p < 0.001) after adjusting for comorbidities in a competing risk model. CONCLUSIONS Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities.
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Affiliation(s)
- Marianne Huebner
- Department of Statistics and Probability, Michigan State University, East Lansing, MI; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| | - Martin Hübner
- Clinic for Visceral Surgery, University of Lausanne, Switzerland
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
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