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Springer JE, Doumouras AG, Lethbridge S, Forbes S, Eskicioglu C. The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey. Can J Surg 2020. [PMID: 33107814 DOI: 10.1503/cjs.009419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.
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Affiliation(s)
| | | | - Sara Lethbridge
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Shawn Forbes
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Cagla Eskicioglu
- From the Department of Surgery, McMaster University, Hamilton, Ont
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The Relationship Between Nutritional Risks and Cancer-Related Fatigue in Patients With Colorectal Cancer Fast-Track Surgery. Cancer Nurs 2018; 41:E41-E47. [DOI: 10.1097/ncc.0000000000000541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Casans-Francés R, Roberto-Alcácer AT, García-Lecina AC, Ferrer-Ferrer ML, Subirá-Ríos J, Guillén-Antón J. Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study. ACTA ACUST UNITED AC 2017; 64:313-322. [PMID: 28214097 DOI: 10.1016/j.redar.2016.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/25/2016] [Accepted: 12/02/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. MATERIAL AND METHODS A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. RESULTS No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). CONCLUSION Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.
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Affiliation(s)
- R Casans-Francés
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - A T Roberto-Alcácer
- Servicio de Urología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - A C García-Lecina
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M L Ferrer-Ferrer
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Subirá-Ríos
- Servicio de Urología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Guillén-Antón
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Casans Francés R, Ripollés Melchor J, Abad-Gurumeta A, Longás Valién J, Calvo Vecino JM. The role of the anaesthesiologist in enhanced recovery programs. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:273-288. [PMID: 26775121 DOI: 10.1016/j.redar.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Affiliation(s)
- R Casans Francés
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España.
| | - J Ripollés Melchor
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - A Abad-Gurumeta
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario La Paz, Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J Longás Valién
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J M Calvo Vecino
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
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Abstract
INTRODUCTION The application of a fast-track recovery program after surgery can decrease the physiological impact of surgery and reduce the duration of hospitalisation compared to conventional care. This program has permitted us to consider the performance of colectomy on an outpatient basis. METHOD After analyzing the recommendations for fast-track recovery, we developed and validated a specific protocol. Drawing on extensive experience in ambulatory surgery (inguinal hernia, cholecystectomy, adjustable gastric-banding), we formalized a protocol for outpatient colectomy. Patient selection criteria were the absence of serious or decompensated comorbidity, very good general condition, and full patient understanding of the procedure. Discharge was authorized if the patient met the exit criteria according to the Chung score. Postoperative surveillance was provided by regular home visits of a nurse trained in enhanced recovery, every afternoon until day 10. RESULTS Five patients underwent this management strategy (4 men and 1 woman, mean age 64 years, range: 59-69), for indications including cancer of the rectosigmoid junction (1 case), sigmoid diverticulitis (3 cases), and volvulus. The postoperative course was simple and uncomplicated except for two patients who had dysuria and an incisional hematoma, respectively. CONCLUSION To our knowledge, these are the first cases of colectomy performed strictly on an outpatient basis (i.e., stay<12h). We demonstrated the feasibility of outpatient colectomy when integrated into a protocol of enhanced recovery for selected patients provided that at-home monitoring was available.
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Affiliation(s)
- B Gignoux
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France.
| | - A Pasquer
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
| | - A Vulliez
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
| | - T Lanz
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
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Lohsiriwat V. Impact of an enhanced recovery program on colorectal cancer surgery. Asian Pac J Cancer Prev 2015; 15:3825-8. [PMID: 24870801 DOI: 10.7314/apjcp.2014.15.8.3825] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Surgical outcomes of colorectal cancer treatment depend not only on good surgery and tumor biology but also on an optimal perioperative care. The enhanced recovery program (ERP) - a multidisciplinary and multimodal approach, or so called 'fast-track surgery' - has been designed to minimize perioperative and intraoperative stress responses, and to support the recovery of organ function aiming to help patients getting better sooner after surgery. Compared with conventional postoperative care, the enhanced recovery program results in quicker patient recovery, shorter length of hospital stay, faster recovery of gastrointestinal function, and a lower incidence of postoperative complications. Although not firmly established as yet, the enhanced recovery program after surgery could be of oncological benefit in colorectal cancer patients because it can enhance recovery, maintain integrity of the postoperative immune system, increase feasibility of postoperative chemotherapy, and shorten the time interval from surgery to chemotherapy. This commentary summarizes short-term outcomes and potential long-term benefits of enhanced recovery programs in the treatment of colorectal cancer.
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Affiliation(s)
- Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand E-mail :
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Shelygin YA, Achkasov SI, Lukashevich IV. [Optimization of postoperative period in patients after colon resection]. Khirurgiia (Mosk) 2015:76-81. [PMID: 26103648 DOI: 10.17116/hirurgia2015476-81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Yu A Shelygin
- State Scientific Coloproctology Center of Russian Medical Academy of Postgraduate Education
| | - S I Achkasov
- State Scientific Coloproctology Center, Health Ministry of the Russian Federation, Moscow
| | - I V Lukashevich
- State Scientific Coloproctology Center, Health Ministry of the Russian Federation, Moscow
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Pearsall EA, Meghji Z, Pitzul KB, Aarts MA, McKenzie M, McLeod RS, Okrainec A. A Qualitative Study to Understand the Barriers and Enablers in Implementing an Enhanced Recovery After Surgery Program. Ann Surg 2015; 261:92-6. [DOI: 10.1097/sla.0000000000000604] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Japanese guidelines for the management of Pain, Agitation, and Delirium in intensive care unit (J-PAD). ACTA ACUST UNITED AC 2014. [DOI: 10.3918/jsicm.21.539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72] [Citation(s) in RCA: 2270] [Impact Index Per Article: 206.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis 2012; 14:1045-51. [PMID: 21985180 DOI: 10.1111/j.1463-1318.2011.02856.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long-term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice. METHOD Medline, Embase and PubMed databases were searched to identify studies that focused on compliance to ERAS protocols during routine clinical practice. Fourteen studies fulfilled the inclusion criteria and a total of 19 perioperative ERAS modalities were identified across these studies. RESULTS None of the studies used all 19 ERAS modalities within their ERAS protocols. Compliance to the various modalities varied considerably between studies and, in general, was poorest during the postoperative period. The use of epidural had the highest compliance (between 67 and 100%), whereas the use of transverse incisions (25%) had the lowest compliance. Length of stay in hospital ranged from 2 to 13 days. Higher compliance was associated with a reduced length of hospital stay. However, reduced length of hospital stay was associated with a high rate of readmission. CONCLUSION There is significant variation in the components of, as well as in compliance to, ERAS protocols in daily practice. This may contribute to the observed variation between the studies in length of hospital stay. A standardized and practically feasible ERAS protocol should be established in order to improve the implementation and optimal outcome.
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Affiliation(s)
- J Ahmed
- Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK.
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12
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Gravante G, Elmussareh M. Enhanced recovery for colorectal surgery: Practical hints, results and future challenges. World J Gastrointest Surg 2012; 4:190-8. [PMID: 23293732 PMCID: PMC3536845 DOI: 10.4240/wjgs.v4.i8.190] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 07/14/2012] [Accepted: 08/02/2012] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient’s preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient’s clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.
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Affiliation(s)
- Gianpiero Gravante
- Gianpiero Gravante, Department of Colorectal Surgery, Pilgrim Hospital, Boston, Lincolnshire PE21 9QS, United Kingdom
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Pozzi G, Falcone A, Sabbatino F, Solej M, Nano M. "Fast track surgery" in the north-west of Italy: influence on the orientation of surgical practice. Updates Surg 2012; 64:131-44. [PMID: 22527810 DOI: 10.1007/s13304-012-0154-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 03/30/2012] [Indexed: 01/24/2023]
Abstract
Fast track surgery is a peri-operative management model, including different strategies to improve patients' convalescence, avoid metabolic alterations, reduce complications, and shorten hospital stay. Prerequisite is coordination between different practitioners (surgeon, anaesthetist, nurse, nutritionist, physiotherapist). The purpose of our investigation is to understand the level of fast track surgery application in Piedmont and to evidence analogies and differences among departments. We projected an investigation proposing, to every surgery department in Piedmont, a multiple-choice questionnaire evaluating the level of fast track surgery peri-operative interventions' application. Data analysis was conducted in two points of view: the transversal one with an overview of answer's percentages, the longitudinal one correlating data through Pearson's index (r). We collected answers by 78 % of balloted departments (38 on 49). Transversal analysis, including the evaluation of percentages of each question, shows that intra-operative period is the most influenced by fast track principles, and that only 12 departments of 38 apply complete protocols. Longitudinal analysis, estimating the whole of each department's answers, demonstrates the absence of statistical significance in the correlation between fast track surgery application and territorial (r = 0.18), economic (r = 0.31), or age (r = 0.06) variables. Influence of fast track surgery is significantly present in our territory, even though it is not fully concretized in protocols. The choice of fast track depends on the instruction, the environment and the sensibility of each surgeon. Knowledge of geographic distribution of departments applying this model can be useful to organize common protocols, starting from more experienced hospitals.
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Affiliation(s)
- G Pozzi
- Clinical and Biological Department, University of Turin, Orbassano, Turin, Italy.
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Gravante G, Elmussareh M. Enhanced recovery for non-colorectal surgery. World J Gastroenterol 2012; 18:205-11. [PMID: 22294823 PMCID: PMC3261537 DOI: 10.3748/wjg.v18.i3.205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/15/2011] [Accepted: 06/22/2011] [Indexed: 02/06/2023] Open
Abstract
In recent years the advent of programs for enhanced recovery after major surgery (ERAS) has led to modifications of long-standing and well-established perioperative treatments. These programs are used to target factors that have been shown to delay postoperative recovery (pain, gut dysfunction, immobility) and combine a series of interventions to reduce perioperative stress and organ dysfunction. With due differences, the programs of enhanced recovery are generally based on the preoperative amelioration of the patient’s clinical conditions with whom they present for the operation, on the intraoperative and postoperative avoidance of medications that could slow the resumption of physiological activities, and on the promotion of positive habits in the early postoperative period. Most of the studies were conducted on elective patients undergoing colorectal procedures (either laparotomic or laparoscopic surgery). Results showed that ERAS protocols significantly improved the lung function and reduced the time to resumption of oral diet, mobilization and passage of stool, hospital stay and return to normal activities. ERAS’ acceptance is spreading quickly among major centers, as well as district hospitals. With this in mind, is there also a role for ERAS in non-colorectal operations?
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Dickson E, Argenta PA, Reichert JA. Results of introducing a rapid recovery program for total abdominal hysterectomy. Gynecol Obstet Invest 2011; 73:21-5. [PMID: 22156551 DOI: 10.1159/000328713] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 04/26/2011] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To review the impact of implementing a rapid recovery protocol (RRP) for patients undergoing abdominal hysterectomy. SETTING Metropolitan teaching hospital. POPULATION Women undergoing abdominal hysterectomy for non-malignant indications. METHODS We conducted a retrospective review of consecutive cases performed during study periods before and after the introduction of an elective rapid recovery program emphasizing regional anesthesia. To control for universal improvements in medical practice, charts from a comparable local hospital without an RRP were also reviewed. RESULTS 400 charts were reviewed and 366 cases met inclusion criteria and had sufficient information. Patients were well matched for demographic and medical variables between the study periods and between the institutions. The median length of stay (LOS) fell dramatically from 3 (range 1-12) days prior to RRP introduction to 1 (range 1-17) day after RRP (p < 0.001). LOS among patients at the 'control' institution remained unchanged at 3 days during the same time frame, indicating that external pressures contributed minimally to the observed changes. There were no significant differences in estimated blood loss, duration of surgery, or complication rate between the groups in either time period. CONCLUSIONS Introducing a rapid recovery program was associated with shorter hospitalization and did not appear to compromise surgical outcome.
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Affiliation(s)
- Elizabeth Dickson
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, Minn., USA
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Levy BF, Scott MJP, Fawcett WJ, Day A, Rockall TA. Optimizing patient outcomes in laparoscopic surgery. Colorectal Dis 2011; 13 Suppl 7:8-11. [PMID: 22098510 DOI: 10.1111/j.1463-1318.2011.02770.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient's outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. 1 Analgesia - The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2 Individualised goal directed therapy - It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach.
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Affiliation(s)
- B F Levy
- Minimal Access Therapy Training Unit, Guildford, UK.
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Donohoe CL, Nguyen M, Cook J, Murray SG, Chen N, Zaki F, Mehigan BJ, McCormick PH, Reynolds JV. Fast-track protocols in colorectal surgery. Surgeon 2011; 9:95-103. [PMID: 21342674 DOI: 10.1016/j.surge.2010.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 07/26/2010] [Accepted: 07/27/2010] [Indexed: 01/22/2023]
Abstract
Fast-track surgery (FTS) is a set of protocols aimed to reduce the physiological burden of surgery thus improving outcomes. FTS aims to use evidence-based practice to reduce complications, improve post-operative quality of life and decrease hospital length of stay. This review seeks to examine the evidence base for protocols employed in colorectal surgery in the areas of pre-operative preparation, anaesthetic management, intraoperative and surgical factors and post-operative care. Despite the evidence that recovery after colorectal surgery can be enhanced by using these approaches, implementation of FTS protocols has been slow. Acceptance of FTS protocols by all members of the multi-disciplinary team and a change in organisational structure to accommodate structured peri-operative care, are imperative to implementation.
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Affiliation(s)
- Claire L Donohoe
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin/St James' Hospital, Dublin 8, Ireland.
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Bethune R. Is the effect because of enhanced recovery rather than the laparoscopic approach? Ann R Coll Surg Engl 2010; 92:720. [PMID: 21047458 DOI: 10.1308/003588410x12771863936440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Varadhan KK, Lobo DN, Ljungqvist O. Enhanced Recovery After Surgery: The Future of Improving Surgical Care. Crit Care Clin 2010; 26:527-47, x. [DOI: 10.1016/j.ccc.2010.04.003] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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