Current preoperative antisepsis in neurosurgery: an example of the challenges in implementing evidence-based medicine to surgical practice

Enhanced recovery after surgery protocols for outpatient operations in otolaryngology: Review of literature

Objective

Enhanced recovery after surgery (ERAS) protocols are patient‐centered, evidence‐based pathways designed to reduce complications, promote recovery, and improve outcomes following surgery. These protocols have been successfully applied for the management of head and neck cancer, but relatively few studies have investigated the applicability of these pathways for other outpatient procedures in otolaryngology. Our goal was to perform a systematic review of available evidence reporting the utility of ERAS protocols for the management of patients undergoing outpatient otolaryngology operations.

Methods

A systematic literature review was conducted using MEDLINE, EMBASE, SCOPUS, and gray literature. We identified studies that evaluated ERAS protocols among patients undergoing otologic, laryngeal, nasal/sinus, pediatric, and general otolaryngology operations. We assessed the outcomes and ERAS components across protocols as well as the study design and limitations.

Results

A total of eight studies fulfilled the inclusion criteria and were included in the analysis. Types of procedures evaluated with ERAS protocols included tonsillectomy and adenoidectomy, functional endoscopic sinus surgery, tympanoplasty and mastoidectomy, and septoplasty. A reduction in postoperative length of stay and hospital costs was reported in two and three studies, respectively. Comparative studies between ERAS and control groups showed persistent improvement in pre‐ and postoperative anxiety and pain levels, without an increase in postoperative complications and readmission rates.

Conclusions

A limited number of studies discuss implementation of ERAS protocols for outpatient operations in otolaryngology. These clinical pathways appear promising for these procedures as they may reduce length of stay, decrease costs, and improve pain and anxiety postoperatively.

Enhanced recovery after surgery (ERAS) protocols in outpatient otolaryngology operations are effective in significantly decreasing hospital length of stay, hospital costs, and postoperative pain/anxiety.

The most common components among ERAS protocols were postoperative analgesia regimen, postoperative nutrition, fluid management, and preoperative education/counseling.

Evidence-based medicine in neurosurgery: why and how?

Since its inception, medical training and practice are based primarily on the clinical experience provided by the mentors of each of the medical schools. In the 1990s, the first steps were taken for the construction of what we now know as evidence-based medicine. Evidence-based medicine is the set of studies, methods, and principles for the prevention of medical diseases, management guidelines, and algorithms used in sources of evidence. Neurosurgery based on evidence has emerged thanks to advances in neuroscience and information technology that allows the globalization of current scientific information. The results of important reviews on the levels of evidence in neurosurgery are low in percentages of high-quality evidence in this field of medicine. Based on the above, the objective of this manuscript is to describe the application of evidence in neurosurgery, the current state of the art in evidence-based medicine, and the steps needed to create evidence of the best quality in neurosurgery.

Comparing Surgeon Adherence with World Health Organization Antiseptic Guidelines for Surgical Site Preparation in the United Kingdom and India

Background: Skin preparation with an antiseptic solution aims to reduce surgical site infection rates. Surgical site infections (SSIs) create a high burden on healthcare systems with impacts on morbidity, mortality, and cost. In 2016, The World Health Organization (WHO) conducted an extensive systematic review and meta-analysis of the existing evidence. From this, they recommended the use of "alcohol based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures." This study aimed to assess surgeon compliance with this guidance in the United Kingdom and India. Methods: A multiple-choice questionnaire was developed to assess surgeon preferences for antiseptic use in their surgical site preparation. The end point of data collection was defined after 50 responses in each region. Results: The majority of respondents in each center was general surgeons (n = 24, 48% United Kingdom; n = 21, 45% India), and registrars (n = 22, 44% United Kingdom; n = 23, 49% India). No surgeon preferred the use of any aqueous preparation. Chlorhexidine gluconate (CHG) was the preparation used most commonly in both centers (n = 30, 64% India; n = 24, 48% United Kingdom). In India, this represented a statistically significant difference (p = 0.0008), however, this was not observed in the United Kingdom (p = 0.22). There were no statistically significant differences between surgeon's reasons between the United Kingdom and India, other than "easier to see" (p = 0.016). Conclusions: This data show a reduced compliance of U.K. surgeons with WHO guidance for antiseptic use compared with Indian surgeons. Although the WHO has attempted to summarize the existing data to minimize the previous uncertainty surrounding antiseptic choices, the use of CHG continues to not be adopted widely. To draw robust conclusions to provide the foundations of further guidelines, future research should focus on prospective randomized controlled trials with large numbers across multiple surgical specialties.