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Murr AT, Sweeney C, Lenze NR, Farquhar DR, Hackman TG. Implementation and Outcomes of ERAS Protocol for Major Oncologic Head and Neck Surgery. Laryngoscope 2024; 134:732-740. [PMID: 37466306 DOI: 10.1002/lary.30904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 06/28/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols have been developed and successfully implemented for many surgical specialties, demonstrating reductions in length of stay, post-operative complications, and resource utilization. Currently, there are few documented applications of ERAS protocols in head and neck surgery. Additional description of head and neck surgery protocol design, implementation, and outcomes will help advance postoperative care. METHODS An ERAS protocol was designed for patients undergoing glossectomy and primary or salvage laryngectomy with or without free flap reconstruction. Following successful protocol implementation, patient outcomes and perioperative metrics were retrospectively reviewed and compared between patients prior to and following the ERAS protocol. RESULTS Global comparison of ERAS and control group did not show statistically significant differences in measured perioperative outcomes. There were no statistically significant differences between the ERAS and control groups in age, sex, BMI, surgery type, or cancer stage. The ERAS protocol was associated with reduced variability in hospital length of stay (LOS), demonstrated through tighter interquartile ranges. For patients undergoing salvage laryngectomy, the ERAS protocol was associated with a significant reduction in 30-day readmission rates. Although not statistically significant, the median length of stay in the step-down unit (ISCU) and hospital was lower for specific patient groups. CONCLUSION The implementation and evaluation of the ERAS protocol demonstrated improvement in select patient outcomes as well as areas for process improvement. This study demonstrates the insights that arise from review of this protocol even for an institution with perceived standardized procedures for major oncologic head and neck surgeries. LEVEL OF EVIDENCE 3 Laryngoscope, 134:732-740, 2024.
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Affiliation(s)
- Alexander T Murr
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Craig Sweeney
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Nicholas R Lenze
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Douglas R Farquhar
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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Nieminen T, Tapiovaara L, Bäck L, Lindford A, Lassus P, Lehtonen L, Mäkitie A, Keski-Säntti H. Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer. Eur Arch Otorhinolaryngol 2024; 281:907-914. [PMID: 37938375 PMCID: PMC10796721 DOI: 10.1007/s00405-023-08292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines. METHODS This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively. RESULTS In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery. CONCLUSIONS We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.
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Affiliation(s)
- Teija Nieminen
- Department of Perioperative and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029 HUS, Helsinki, Finland.
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Laura Tapiovaara
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leif Bäck
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrew Lindford
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Lassus
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Harri Keski-Säntti
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Jani A, Chaudhry K, Kaur A, Bhatia PK, Kumar P, Gigi PG, Batra T, Chugh A. Efficacy of Enhanced Recovery after Surgery (ERAS) protocol in maxillofacial trauma: A randomized controlled trial. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101576. [PMID: 37544506 DOI: 10.1016/j.jormas.2023.101576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/06/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Enhanced Recovery after surgery (ERAS) guidelines have been formulated in the literature for various different specialties but none is present for maxillofacial trauma patients. Hence, we have formulated ERAS protocol for maxillofacial trauma (ERAS-MT) patients and compared with the patients receiving the standard traditional care for post trauma outcomes. METHODOLOGY A randomized controlled trial included 74 patients divided into two groups: Group 1 (ERAS group:37 patients) and Group II (Control group:37 patients). ERAS group were intervened according to the formulated ERAS protocol based on the previous literature and the control group received the standard of care. The both groups were compared for various post trauma outcomes. RESULTS Baseline demographic data was non-significant between both the groups. There was significant decrease in pre-operative IV fluid use and total number of IV analgesics used till 72 h as well as in the immediate post operative period in the ERAS group(p = 0.001). ERAS group started oral feeds within 6 h and they were significantly compliant for oral carbohydrates in the pre-operative phase(p = 0.001). PONV episodes, swelling and infections were insignificantly less in the ERAS group(p > 0.05), however a significant difference was seen throat pain and decreased anxiety as well as Oral Hygiene Index(p = 0.001). At two weeks, a significant difference was seen in overall patient's satisfaction and cost analysis in the ERAS group (p = 0.001). CONCLUSION Our study suggested that ERAS protocol was associated with shorter hospital stay, early recovery with better overall satisfaction of the patients, lesser post-operative complications and significantly decreased cost analysis.
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Affiliation(s)
- Astha Jani
- All India Institute of Medical Sciences, Jodhpur, India
| | | | - Amanjot Kaur
- All India Institute of Medical Sciences, Vijaypur, Jammu, India
| | | | - Pravin Kumar
- All India Institute of Medical Sciences, Jodhpur, India
| | - P G Gigi
- All India Institute of Medical Sciences, Jodhpur, India
| | - Tanya Batra
- All India Institute of Medical Sciences, Jodhpur, India
| | - Ankita Chugh
- All India Institute of Medical Sciences, Jodhpur, India.
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Imai T, Takasago T, Momma Y, Chiba T, Nakanome A, Morita S, Hasegawa K, Ito K, Goto T, Asada Y. Efficacy of an enhanced recovery after surgery pathway to manage pain, nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. Jpn J Clin Oncol 2023; 53:1038-1044. [PMID: 37534546 DOI: 10.1093/jjco/hyad094] [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: 05/12/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Pain and post-operative nausea and vomiting are the main factors that impair the quality of recovery after surgery. Very few reports have analyzed patient-reported outcomes to investigate the efficacy of an enhanced recovery after surgery protocol to alleviate these symptoms after head and neck surgeries with free tissue transfer reconstruction. METHODS We investigated post-operative pain and post-operative nausea and vomiting in 47 patients who underwent head and neck surgeries with free tissue transfer reconstruction with enhanced recovery after surgery support between February 2021 and August 2022. Patient-reported outcomes were assessed using the visual analog scale and Japanese version of the Quality of Recovery-40. RESULTS Significant increases in the mean visual analog scale scores for pain and post-operative nausea and vomiting were observed only on post-operative Day 1 compared with preoperative values (pain: 3.19 ± 2.78 vs. 1.96 ± 2.42, P = 0.0408; post-operative nausea and vomiting: 1.52 ± 2.09 vs. 0.54 ± 1.37, P = 0.0194). From post-operative Day 2, there were no significant differences between the pre- and post-operative visual analog scale scores, and no significant increases in the incidences of moderate or severe pain and post-operative nausea and vomiting compared with preoperatively. The Japanese version of the Quality of Recovery-40 score for post-operative pain showed no significant deterioration compared with preoperatively, while the Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting showed significant deterioration compared with the preoperative value on post-operative Days 2, 4 and 7. CONCLUSIONS The visual analog scale and Japanese version of the Quality of Recovery-40 scores for post-operative pain and visual analog scale score for post-operative nausea and vomiting suggested that the enhanced recovery after surgery strategy favorably controlled pain and post-operative nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. However, as the post-operative Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting was lower than the preoperative value, there is still a need for further improvement of the enhanced recovery after surgery pathway.
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Affiliation(s)
- Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Teiko Takasago
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Yumiko Momma
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Tomoyo Chiba
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Ayako Nakanome
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Sinkichi Morita
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kohsei Hasegawa
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kazue Ito
- Department of Head and Neck Medical Oncology, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Takahiro Goto
- Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
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Govil N, Tripathi M, Parag K, Agrawal SP, Kumar M, Varshney S. Role of protocol-guided perioperative care to enhance recovery after head and neck neoplasm surgery: An institutional experience. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:491-500. [PMID: 37678465 DOI: 10.1016/j.redare.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/30/2022] [Indexed: 09/09/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) improve recovery after surgery. This study aimed to determine whether ERAS leads to a decrease in stay in the hospital and improves global and functional recovery after head and neck neoplasms surgery. METHODS We performed a prospective case and historical control study after the ERAS application. The hospital database selected 50 confirmed eligible patients in control non-ERAS group. Prospectively 54 patients were included in the ERAS group. The primary outcome was time to readiness for discharge (TRD); secondary outcomes were the length of stay (LOS), readmission rate of up to 30 days and Quality of recovery score QoR-15. Data were compared with appropriate parametric and nonparametric tests. RESULTS Baseline demographic data of patients were comparable between the two groups. Patients in ERAS group had significantly shorter TRD compared to the non-ERAS group 8 (6-10) vs 11 (8-16); p-value = 0.002. LOS was also significantly shorter in the ERAS group compared to the non-ERAS group [8 (7-11) vs 12 (9-17); p-value = 0.002]. Readmission at 30-days was no different, with six patients in each group. QoR-15 score was statistically better in ERAS group (94.88 ± 12.50) compared to non-ERAS group (85.44 ± 12.68) [p value < 0.001]. CONCLUSION Implementing the ERAS programme decreased TRD and LOS and improved patient-reported recovery outcome QoR-15 in head and neck neoplasms surgery.
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Affiliation(s)
- N Govil
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India.
| | - M Tripathi
- Institute of Medical Sciences Mangalagiri, Mangalagiri, India
| | - K Parag
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - S P Agrawal
- Department of Otorhinolaryngology-Head & Neck Surgery, AIIMS Rishikesh, Rishikesh, India
| | - M Kumar
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - S Varshney
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
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Aleid A, Alyaseen EM, Alfurayji RS, Alanazi BS, Alquraish FA, Al Mutair A, Alessa M, Albinsaad L. Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness. Cureus 2023; 15:e49448. [PMID: 38152784 PMCID: PMC10751604 DOI: 10.7759/cureus.49448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.
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Affiliation(s)
| | - Eman M Alyaseen
- College of Medicine and Medical Science, Arabian Gulf University, Manama, BHR
| | | | - Bader S Alanazi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | | | - Mohammed Alessa
- Department of Surgery, College of Medicine, King Faisal University, Hofuf, SAU
| | - Loai Albinsaad
- Department of Surgery, King Faisal University, Hofuf, SAU
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Willer BL, Alalade E, Toledo P, Jimenez N. Pro-Con Debate: Perioperative Research Should Be Color-Blind. Anesth Analg 2023; 137:967-972. [PMID: 37862397 DOI: 10.1213/ane.0000000000006258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Profound racial and ethnic disparities have been documented in health and health care outcomes in recent decades. Some researchers have erroneously ascribed these inequities to biological variations, prompting debate as to how, or even if, race and ethnicity should be included as an outcome variable. Color blindness is a racial ideology with roots in constitutional law that posits that equality is best achieved by disregarding the racial and ethnic characteristics of the individual. Color consciousness, in contrast, approaches disparities with the knowledge that experiences related to one's race and ethnicity influence an individual's health and well-being. In this Pro-Con commentary article, we discuss the concept of color blindness and debate its use as an approach in medicine and research.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Emmanuel Alalade
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Paloma Toledo
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Nathalia Jimenez
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, Washington
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List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
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Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
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Hanba C, Lewis C. Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction. Otolaryngol Clin North Am 2023; 56:801-812. [PMID: 37380326 DOI: 10.1016/j.otc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.
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Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Carol Lewis
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Sameer M, Muthu S, Vijayakumar PC. Enhanced Recovery After Surgery (ERAS) Protocol in Geriatric Hip Fractures: An Observational Study. Cureus 2023; 15:e42073. [PMID: 37602104 PMCID: PMC10434293 DOI: 10.7759/cureus.42073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
INTRODUCTION Geriatric hip fractures are the new global pandemic. It is predicted to reach 7.3-21.3 million cases worldwide by 2050. Even with optimal care, geriatric patients suffer a higher morbidity and mortality rate when compared with the general population and often demand expensive hospital aftercare. This study aims to assess the implications of the successful adoption of the enhanced recovery after surgery (ERAS) protocol in the management of geriatric hip fractures in an Indian facility. METHODS This is a retrospective study conducted in a tertiary care hospital in India and reported following REporting of studies Conducted using the Observational Routinely collected health Data (RECORD) guidelines. We included all geriatric patients over 60 years of age who were admitted with hip fractures for surgical management between January 2021 and January 2023. The individual perioperative components of the ERAS protocol focus on key areas such as preoperative nutritional support, effective multimodal analgesia with optimal pain control, fluid management, and early postoperative mobilization. RESULTS Thirty-eight geriatric patients with a mean age of 77.5 (± 9.6) years were included for analysis. Twenty-three patients sustained intertrochanteric fractures and underwent fixation with proximal femur nailing and the remaining had 15 sustained neck or femur fractures of which 11 underwent hemiarthroplasty surgery and the remaining four underwent a total hip replacement. The mean time to surgery was 2 (± 0.2) days. Eighty-two percent (n=31) of the patients were mobilized with a walking frame within a day after surgery and were followed up after discharge with home physiotherapy. The mean time to ambulation was 2 (± 0.62) days. The mean length of stay was 4 (± 1.6) days. We had a 30-day readmission rate of 5.2% (n=2) and a 30-day mortality rate of 5.2% (n=2). The one-year mortality rate was 13% (n=5). CONCLUSION Management of geriatric hip fractures requires exceptional interdisciplinary coordination and carefully planned strategies to optimize patient care. With the implementation of the ERAS protocol, we could perceive clinical benefits in terms of early recovery and short length of hospital stay in patients with hip fractures. Further comparative studies are required, which can determine the relative importance of individual measures in the ERAS protocol and understand their longer-term outcomes in hip fracture surgeries.
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Affiliation(s)
- Mohamed Sameer
- Department of Orthopaedics, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Sathish Muthu
- Department of Orthopaedics, Orthopaedic Research Group, Coimbatore, IND
- Department of Biotechnology, Faculty of Engineering, Karpagam Academy of Higher Education, Coimbatore, IND
- Department of Orthopaedics, Government Medical College, Dindigul, IND
| | - P C Vijayakumar
- Department of Anaesthesiology, Sooriya Hospital, Chennai, IND
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Kattar N, Wang SX, Trojan JD, Ballard CR, McCoul ED, Moore BA. Enhanced Recovery After Surgery Protocols for Head and Neck Cancer: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2023; 168:593-601. [PMID: 35290105 DOI: 10.1177/01945998221082541] [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: 10/22/2021] [Accepted: 01/28/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction. DATA SOURCES PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators. REVIEW METHODS This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series. RESULTS Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; I2 = 0%; P < .00001) with the ERAS group as compared with non-ERAS controls. The standardized mean difference of the morphine milligram equivalent was 0.72 lower (95% CI, 0.26-1.18; I2 = 82%; P = .002) in the ERAS group vs controls. The quality of studies was moderate with a median MINORS score of 18.5 (range, 13.5-21.5). CONCLUSION Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.
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Affiliation(s)
- Nrusheel Kattar
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Steven X Wang
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Jeffrey D Trojan
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Craig R Ballard
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of Queensland, New Orleans, Louisiana, USA
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Brian A Moore
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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Abstract
Striving to optimize surgical outcomes, the Enhanced Recovery After Surgery (ERAS) pathway mitigates patients' stress through the implementation of evidence-based practices during the pre-, intra-, and postoperative periods. Intestinal flora is a sophisticated ecosystem integrating with the host and the external environment, which serves as a mediator in diverse interventions of ERAS to regulate human metabolism and inflammation. This review linked gut microbes and their metabolites with ERAS interventions, offering novel high-quality investigative proponents for ERAS. ERAS could alter the composition and function of intestinal flora in patients by alleviating various perioperative stress responses. Modifying gut flora through multiple modalities, such as diet and nutrition, to accelerate recovery might be a complementary approach when exploring novel ERAS initiatives. Meanwhile, the pandemic of COVID-19 and the availability of promising qualitative evidence created both challenges and opportunities for the establishment of ERAS mode.
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Castellanos CX, Paoletti M, Ulloa R, Kim C, Fong M, Xepoleas M, Sinha U, Kokot N, Swanson MS. Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction. OTO Open 2023; 7:e17. [PMID: 36998552 PMCID: PMC10046737 DOI: 10.1002/oto2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/23/2022] [Indexed: 03/15/2023] Open
Abstract
Objective To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS). Study Design Single institution retrospective cohort study. Setting TORS was performed at a single academic tertiary care center. Methods This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge. Results A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001). Conclusion Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.
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Affiliation(s)
- Carlos X. Castellanos
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Marcus Paoletti
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ruben Ulloa
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Celeste Kim
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Michelle Fong
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Meredith Xepoleas
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Uttam Sinha
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Niels Kokot
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark S. Swanson
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
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14
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Elmer NA, Baltodano PA, Webster T, Deng M, Egleston B, Massada K, Kaplunov B, Brebion R, Araya S, Patel S. Critical Importance of the First Postoperative Days After Head and Neck Free Flap Reconstruction: An Analysis of Timing of Reoperation Using the National Surgical Quality Improvement Program Database. Ann Plast Surg 2022; 89:295-300. [PMID: 35993684 PMCID: PMC10103626 DOI: 10.1097/sap.0000000000003260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Head and neck free flaps remain associated with considerable rates of take-back and prolonged hospital length of stay. However, there have been no studies on a national level benchmarking the timeline and predictors of head and neck free flap take-back. METHODS Patients undergoing head and neck free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 database were analyzed to determine the rates of take-back. Timing and rates of unplanned head and neck free flap take-backs were stratified by tissue type and postoperative day (POD) over the first month. Weibull survival models were used to compare rates of take-backs among time intervals. Multivariable logistic regression was used to identify the independent predictors of take-back. RESULTS Three thousand nine hundred six head and neck free flaps were analyzed. The mean daily proportion of patients experiencing take-back during PODs 0 to 1 was 0.95%; this dropped significantly to a mean daily proportion of 0.54% during POD 2 (P < 0.01). In addition, there were significant drops in take-back when comparing POD 2 (0.54%) to POD 3 (0.26%) and also when comparing POD 4 (0.20%) with PODs 5 to 30 (0.032% per day) (P < 0.05). The soft tissue and osseous flap populations demonstrated a similar trend in unplanned take-back. CONCLUSION This is the first national study to specifically analyze the timing of take-back in the head and neck reconstruction population. These data highlight the importance of flap monitoring during the first 5 PODs, with ERAS pathway optimization aiming for discharge by the end of the first postoperative week.
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Affiliation(s)
| | - Pablo A. Baltodano
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Theresa Webster
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Mengying Deng
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen Massada
- Mercy Catholic Medical Center Division of General Surgery, Philadelphia, PA
| | - Briana Kaplunov
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Rohan Brebion
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Sthefano Araya
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Sameer Patel
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
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15
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Jian C, Zhou Z, Guan S, Fang J, Chen J, Zhao N, Bao H, Li X, Cheng X, Zhu W, Yang C, Shu X. Can an incomplete ERAS protocol reduce postoperative complications compared with conventional care in laparoscopic radical resection of colorectal cancer? A multicenter observational cohort and propensity score-matched analysis. Front Surg 2022; 9:986010. [PMID: 36090330 PMCID: PMC9458933 DOI: 10.3389/fsurg.2022.986010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The patients undergoing laparoscopic radical colorectomy in many Chinese hospitals do not achieve high compliance with the ERAS (enhanced recovery programs after surgery) protocol. Methods The clinical data from 1,258 patients were collected and divided into the non-ERAS and incomplete ERAS groups. Results A total of 1,169 patients were screened for inclusion. After propensity score-matched analysis (PSM), 464 pairs of well-matched patients were generated for comparative study. Incomplete ERAS reduced the incidence of postoperative complications (p = 0.002), both mild (6.7% vs. 10.8%, p = 0.008) and severe (3.2% vs. 6.0%, p = 0.008). Statistically, incomplete ERAS reduced indirect surgical complications (27,5.8% vs. 59, 12.7) but not local complications (19,4.1% vs. 19, 4.1%). The subgroup analysis of postoperative complications revealed that all patients benefited from the incomplete ERAS protocol regardless of sex (male, p = 0.037, 11.9% vs. 17.9%; female, p = 0.010, 5.9% vs. 14.8%) or whether neoadjuvant chemotherapy was administered (neoadjuvant chemotherapy, p = 0.015, 7.4% vs. 24.5%; no neoadjuvant chemotherapy, p = 0.018, 10.2% vs. 15.8%). Younger patients (<60 year, p = 0.002, 7.6% vs. 17.5%) with a low BMI (<22.84, 9.4% vs. 21.1%, p < 0.001), smaller tumor size (<4.0 cm, 8.1% vs. 18.1%, p = 0.004), no fundamental diseases (8.8% vs. 17.0%, p = 0.007), a low ASA score (1/2, 9.7% vs. 16.3%, p = 0.004), proximal colon tumors (ascending/transverse colon, 12.2% vs. 24.3%, p = 0.027), poor (6.1% vs. 23.7%, p = 0.012)/moderate (10.3% vs. 15.3%, p = 0.034) tumor differentiation and no preoperative neoadjuvant radiotherapy (10.3% vs. 16.9%, p = 0.004) received more benefit from the incomplete ERAS protocol. Conclusion The incomplete ERAS protocol decreased the incidence of postoperative complications, especially among younger patients (<60 year) with a low BMI (<22.84), smaller tumor size (<4.0 cm), no fundamental diseases, low ASA score (1/2), proximal colon tumors (ascending/transverse colon), poor/moderate differentiation and no preoperative neoadjuvant radiotherapy. ERAS should be recommended to as many patients as possible, although some will not exhibit high compliance. In the future, the core elements of ERAS need to be identified to improve the protocol.
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Affiliation(s)
- Chenxing Jian
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Zili Zhou
- Department of Gastrointestinal Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shen Guan
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jianying Fang
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Jinhuang Chen
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Zhao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haijun Bao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xianguo Li
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xukai Cheng
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhong Zhu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunkang Yang
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Xiaogang Shu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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16
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Bertazzoni G, Testa G, Tomasoni M, Mattavelli D, Del Bon F, Montalto N, Ferrari M, Andreoli M, Morello R, Sbalzer N, Vecchiati D, Piazza C, Nicolai P, Deganello A. The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:325-333. [PMID: 36254650 PMCID: PMC9577693 DOI: 10.14639/0392-100x-n2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
Objective In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre. Methods Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018. Results Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140). Conclusions Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.
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Affiliation(s)
- Giacomo Bertazzoni
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy,Correspondence Giacomo Bertazzoni Department of Otorhinolaryngology Azienda Socio-Sanitaria Territoriale di Cremona, viale Concordia 1, 26100 Cremona, Italy Tel. +39 0372 405282 E-mail:
| | - Gabriele Testa
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Tomasoni
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy, Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Nausica Montalto
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Andreoli
- Clinical Nutrition, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Riccardo Morello
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy
| | - Nicola Sbalzer
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Daniela Vecchiati
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | | | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
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17
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Højvig JH, Charabi BW, Wessel I, Jensen LT, Nyberg J, Maymann-Holler N, Kehlet H, Bonde CT. Enhanced recovery after microvascular reconstruction in head and neck cancer – A prospective study. JPRAS Open 2022; 34:103-113. [PMID: 36263192 PMCID: PMC9573822 DOI: 10.1016/j.jpra.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives Patients undergoing microvascular reconstruction after head and neck cancer typically have several comorbidities, and the procedures are often followed by complications and prolonged hospitalization. Consequently, the application of enhanced recovery after surgery (ERAS) for these patients undergoing microvascular reconstruction has gained attention in recent years. ERAS is a peri- and postoperative care concept that has repeatedly shown beneficial results for a wide variety of surgical procedures, including microvascular reconstruction. This study presents the results after the introduction of our ERAS protocol for head and neck cancer reconstruction. Methods We prospectively treated 30 consecutive patients according to our ERAS protocol from June 2019 to December 2020 and compared the results of the treated patients with those of patients treated with our traditional recovery after surgery (TRAS) protocol. We are based on our ERAS protocol on the following core elements of recovery: improved patient information, goal-directed fluid therapy, minimally invasive surgery, opioid-sparing multimodal analgesia, early ambulation, and pre-defined functional discharge criteria. Results The baseline characteristics of the groups were comparable. The ERAS group had a significantly shorter length of stay (13.1 vs. 20.3 days, p < 0.001), significantly shorter time to ambulation (3.0 days vs. 6.4 days, p < 0.001), shorter time to removal of nasogastric tube (13.3 days vs. 22.7 days, p = 0.05), and fewer tracheostomies performed (10% vs. 90%, p < 0.001). There were no differences in complications, flap survival, or 30-day re-admissions between the two groups. Conclusion The introduction of ERAS in patients with head and neck cancer undergoing microvascular reconstruction seems safe and results in improved recovery. Level of evidence 3
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18
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Kiong KL, Moreno A, Vu CN, Zheng G, Rosenthal DI, Weber RS, Lewis CM. Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival. Oral Oncol 2022; 130:105906. [PMID: 35594776 DOI: 10.1016/j.oraloncology.2022.105906] [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: 11/15/2021] [Revised: 04/09/2022] [Accepted: 05/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC. METHODS 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined. RESULTS Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521). CONCLUSION ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.
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Affiliation(s)
- Kimberley L Kiong
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Amy Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Catherine N Vu
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gang Zheng
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Prasad A, Chorath K, Barrette L, Go B, Deng J, Moreira A, Rajasekaran K. Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices. World J Otorhinolaryngol Head Neck Surg 2022; 8:91-95. [PMID: 35782405 PMCID: PMC9242413 DOI: 10.1002/wjo2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/03/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Aman Prasad
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Kevin Chorath
- Department of Otorhinolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
| | - Louis‐Xavier Barrette
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Beatrice Go
- Department of Otorhinolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
| | - Jie Deng
- School of Nursing, Laboratory of Innovative & Translational Nursing Research University of Pennsylvania Philadelphia Pennsylvania USA
| | - Alvaro Moreira
- Department of Pediatrics University of Texas Health San Antonio San Antonio Texas USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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20
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Chen S, Sumer BD. Editorial Comment on "Enhanced Recovery After Surgery (ERAS) in Head and Neck Oncologic Surgery: A Case-Matched Analysis of Perioperative and Pain Outcomes". Ann Surg Oncol 2020; 28:604-605. [PMID: 33175261 DOI: 10.1245/s10434-020-09337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Shuqing Chen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Baran D Sumer
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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