Enhanced Recovery After Surgery: Exploring the Advances and Strategies

Efficacy of Nursing-Led Physiotherapy for Post-Surgical Foot and Ankle Outcomes in Haglund Deformity: A Pilot Study

This pilot study aimed to evaluate the preliminary impact of a nursing-led physiotherapy protocol on foot and ankle outcomes in patients undergoing resection of Haglund deformity. This quasi-experimental pre-posttest study with a control group followed Transparent Reporting of Evaluations with Nonrandomized Designs guidelines and was conducted in the physiotherapy units of the Main University Hospital and Nariman Hospital in Alexandria, Egypt. A convenience sample of 60 adult patients (30 in a study group and 30 in a control group) participated. Data collection tools included a demographic and clinical data interview schedule and the Foot and Ankle Outcome Score. The structured physiotherapy intervention showed potential benefits in improving health-related measures in the study group compared to the control group. Pain scores in the study group decreased from a mean of 24.20 (SD = 0.96) pre-intervention to 5.57 (SD = 2.24) post-intervention (T2 = 40.127, p < 0.001), while the control group showed minimal change. Other symptom scores dropped from 26.47 (SD = 3.05) to 9.50 (SD = 2.64) (T2 = 13.743, p < 0.001). Activities of daily living improved, with scores decreasing from 49.77 (SD = 7.74) to 12.33 (SD = 4.16) (T2 = 44.118, p < 0.001). Sports and recreation scores fell from 15.00 (SD = 2.23) to 4.93 (SD = 1.84) (T2 = 26.276, p < 0.001), and quality of life improved from 12.47 (SD = 2.08) to 4.00 (SD = 1.36) (T2 = 28.825, p < 0.001). The total foot and ankle outcome score also improved significantly, decreasing from 127.90 (SD = 9.65) to 36.33 (SD = 5.50) (T2 = 65.093, p < 0.001). Findings from this pilot study suggest that a structured postoperative physiotherapy protocol may contribute to pain reduction and improved recovery following Haglund deformity resection. However, these results should be considered preliminary, and further research using randomized controlled trials is needed to validate these findings before drawing definitive clinical recommendations.

Impact of "Enhanced Recovery After Surgery" (ERAS) protocols vs. traditional perioperative care on patient outcomes after colorectal surgery: a systematic review

BACKGROUND

Colorectal surgery is associated with a high risk of postoperative complications, including technical complications, surgical site infections, and other adverse events affecting patient safety and overall patient experience. "Enhanced Recovery After Surgery" (ERAS) is considered a new standard of care for streamlining the perioperative care of surgical patients with the goal of minimizing complications and optimizing timely patient recovery after surgery. This systematic review was designed to investigate the evidence-based literature pertinent to comparing patient outcomes after ERAS versus conventional perioperative care.

METHODS

This systematic review evaluates the performance of ERAS protocols against conventional care in colorectal surgery, focusing on various postoperative outcome measures. An extensive search was conducted across multiple electronic databases and registers from July 2 to July 5, 2024, complemented by citation searching on November 30, 2024. This approach led to the identification of 11 randomized controlled trials (RCTs) from the past decade, involving 1,476 adult participants. To ensure methodological rigor and transparency, the review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines and was registered with PROSPERO (CRD42024583074).

RESULTS

The implementation of ERAS protocols resulted in a notable decrease in hospital stay duration compared to conventional care, with reductions varying between 3 and 8 days across studies. ERAS patients also had faster gastrointestinal recovery, including quicker times to bowel movement, defecation, and resumption of normal diet. Furthermore, patients in ERAS groups showed notably reduced postoperative complications and opioid consumption, with patients experiencing lower pain scores on the Visual Analogue Scale (VAS) and reduced reliance on opioids. Additionally, nutritional recovery in ERAS patients was enhanced, with elevated albumin and total protein levels, alongside decreased inflammatory markers and improved immune function.

CONCLUSION

This systematic review provides compelling evidence supporting the integration of ERAS protocols into standard colorectal surgical practices. Future studies should aim to explore the variations in ERAS implementation, pinpoint the most impactful elements of ERAS, and work towards personalizing and standardizing these protocols across clinical settings. Additionally, evaluating long-term outcomes will help refine ERAS strategies, ensuring their enduring impact on patient recovery.

Effectiveness of Prehabilitation Programs in Reducing the Length of Hospital Stay and Complication Rates in Major Surgeries: A Systematic Review

Prehabilitation, involving physical, nutritional, and psychological interventions before surgery, has emerged as a promising strategy to improve postoperative outcomes. This systematic review evaluated the impact of prehabilitation programs across various surgical systems, including cardiac, abdominal, colorectal, and thoracic surgeries. Data were synthesized from meta-analyses and systematic reviews to assess the effectiveness of uni- and multimodal prehabilitation interventions. Findings demonstrate that multimodal prehabilitation, particularly combining exercise and nutrition, significantly reduces postoperative complications, enhances functional recovery, and shortens hospital length of stay (LoS). While benefits were observed across surgical systems, variability in outcomes was noted due to differences in intervention design and patient populations. The review highlights the adaptability of prehabilitation and underscores its potential as a cost-effective and scalable approach to optimize surgical outcomes. However, gaps remain in standardizing protocols and evaluating long-term benefits, particularly for underrepresented surgeries such as spine and thoracic procedures. These findings support the integration of tailored prehabilitation programs into perioperative care and emphasize the need for further high-quality research.

ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.

Evaluating Short-Term Patient-Reported Outcome Measures Following Total Hip and Knee Replacement: A Comprehensive Review

Total hip replacement (THR) and total knee replacement (TKR) are widely performed surgical procedures to alleviate pain and improve function in patients with joint-related diseases. Short-term patient-reported outcome measures (PROMs) have become a key metric in assessing the success of these surgeries from the patient's perspective, focusing on early recovery, pain management, mobility, and quality of life. This comprehensive review evaluates the significance of short-term PROMs following THR and TKR, highlighting commonly used tools such as the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and short-form health survey (SF-36). The analysis explores the impact of various factors, such as age, preoperative health status, and surgical technique, on short-term outcomes. Findings from recent studies indicate that while patients generally report improvements in physical function and pain relief within the first six months post-surgery, individual outcomes can vary significantly. Factors like early rehabilitation, mental health, and the presence of postoperative complications can influence the trajectory of recovery and satisfaction levels. Moreover, the review addresses the limitations of current PROMs, including variability in reporting and sensitivity to different patient populations. This review emphasizes the need for more personalized and standardized approaches to PROM assessment to better capture patient experiences and optimize postoperative care. Future research should focus on integrating PROMs with long-term follow-up data and digital health tools to track real-time patient progress, thus enhancing the overall quality of care for THR and TKR patients. Short-term PROMs play a vital role in understanding patient outcomes and guiding clinical practice for joint replacement surgeries.

Extracapsular Dissection Versus Traditional Parotid Surgery: A Comprehensive Review of Techniques and Outcomes

Parotid tumours, encompassing both benign and malignant forms, present significant challenges in surgical management. Traditional parotid surgery, including various forms of parotidectomy, has long been the standard approach, aiming for complete tumour removal while addressing potential complications such as facial nerve injury. However, extracapsular dissection (ECD) has emerged as an alternative technique, focusing on excising the tumour along with a thin layer of surrounding tissue, which may offer benefits in preserving healthy glandular tissue and reducing postoperative complications. This review comprehensively compares ECD and traditional parotid surgery techniques, evaluating their efficacy, outcomes, and associated complications. We analyse clinical studies and evidence to assess differences in tumour recurrence rates, facial nerve function preservation, and overall patient recovery. Additionally, the review explores the indications for each surgical approach, considering tumour characteristics and patient-specific factors. The findings suggest that while ECD may offer advantages in terms of reduced postoperative complications and improved preservation of glandular tissue, traditional parotidectomy remains a robust method for managing complex cases. This review aims to inform clinical decision-making by presenting a detailed comparison of both techniques, ultimately guiding surgeons in selecting the most appropriate approach for individual patients.

Exploring the effects of post operative hyperoxic intermittent stimuli on reticulocyte levels in cancer patients: a randomized controlled study

BACKGROUND

Anemia is common among hospitalized critically ill and surgical oncological patients. The rising incidence of cancer and aggressive treatments has increased the demand for blood products, further strained by a dwindling donor pool. The normobaric oxygen paradox (NOP) has emerged as a potential avenue to increase EPO levels. While some studies support its efficacy, research remains limited in clinical settings. This study aims to assess the effectiveness of a NOP protocol in stimulating erythropoiesis, as measured by changes in reticulocyte counts, in cancer patients undergoing abdominal surgeries.

METHODS

This is a post hoc analysis of a prospective, single-center, controlled, randomized study. A total of 49 patients undergoing abdominal surgery were analyzed at the Institut Jules Bordet. Adult patients admitted to the intensive care unit (ICU) for at least 24 h were enrolled, excluding those with severe renal insufficiency or who received transfusions during the study period. Participants were randomized into two groups: a normobaric oxygen paradox (OXY) group who received 60% oxygen for 2 h on days 1, 3, and 5 post-surgery and a control (CTR) group who received standard care. Data on baseline characteristics, surgical details, and laboratory parameters were collected. Statistical analysis included descriptive statistics, chi-square tests, t-tests, Mann-Whitney tests, and linear and logistic regression.

RESULTS

The final analysis included 33 patients (median age 62 [IQR 58-66], 28 (84.8%) males, with no withdrawals or deaths during the study period. No significant differences were observed in baseline surgical characteristics or perioperative outcomes between the two groups. In the OXY group (n = 16), there was a significant rise (p = 0.0237) in the percentage of reticulocyte levels in comparison to the CTR group (n = 17), with median values of 36.1% (IQR 20.3-57.8) versus - 5.3% (IQR - 19.2-57.8), respectively. The increases in hemoglobin and hematocrit levels did not significantly differ between the groups when compared to their baselines' values.

CONCLUSIONS

This study provides preliminary evidence supporting the potential of normobaric oxygen therapy in stimulating erythropoiesis in cancer patients undergoing abdominal surgeries. While the OXY group resulted in increased reticulocyte counts, further research with larger sample sizes and multi-center trials is warranted to confirm these findings.

TRIAL REGISTRATION

The study was retrospectively registered under NCT number 06321874 on The 10th of April 2024.

Initial Results of the Enhanced Recovery After Surgery (ERAS) Program in Patients Undergoing Lobectomy in the Treatment of Lung Cancer: An Experience From the University Medical Center Ho Chi Minh City

BACKGROUND

Lobectomy is a standard surgical method in the treatment of early stages of non-small cell lung cancer (NSCLC). The enhanced recovery after surgery (ERAS) program aims to reduce the postoperative length of hospital stay (PLOS) in major surgeries. This study evaluated the impact of the ERAS program on PLOS and identified related factors in patients undergoing lobectomy for NSCLC.

METHODS

This prospective observational study was conducted at the University Medical Center Ho Chi Minh City, Vietnam, from February 2022 to December 2023. We included patients diagnosed with NSCLC scheduled for lobectomy. The ERAS protocol was applied according to guidelines from the ERAS Society and the French Society of Anaesthesia and Intensive Care Medicine. We collected data on patient demographics, surgical details, adherence to the ERAS protocol, and postoperative outcomes, including the PLOS.

RESULTS

Among the 98 patients enrolled, the median PLOS after ERAS intervention was 4.1 days (interquartile range: 3.7 to 5.2 days). Adherence to ERAS protocols significantly correlated with reduced PLOS (p<0.001). Notably, smoking status was identified as a related factor of PLOS (p=0.002). Complications (p<0.001), surgical method (p=0.007), operation time (p<0.001), duration of postanesthesia care unit (p=0.006), duration of thoracic drainage (p<0.001), and urinary catheter retention time (p=0.023) were also associated with PLOS variations.

CONCLUSION

Implementing the ERAS program in patients undergoing lobectomy for NSCLC at our center reduced PLOS and highlighted the importance of protocol adherence for optimizing surgical outcomes. These findings supported the broader adoption of ERAS protocols in thoracic surgery to enhance patient recovery. Future research should focus on multi-center studies to generalize these results and further dissect the impact of individual ERAS components.

Length of Postoperative Hospital Stay and Related Factors After Lobectomy for Lung Cancer: A Pre-enhanced Recovery After Surgery (ERAS) Single Center Assessment

BACKGROUND

Lobectomy for lung cancer often presents a lot of potentially severe complications after surgery for patients. Enhanced Recovery After Surgery (ERAS) is a program to improve unexpected events. When implementing ERAS, there needs to be evidence of relevant factors that prolong hospital stays to encourage the participation of medical staff and leaders. This study is to determine the length of hospital stay (LOS) and its related factors after surgery in patients undergoing lobectomy for non-small cell lung cancer.

METHODS

 A descriptive retrospective study was conducted on 99 patients undergoing lobectomy for non-small cell lung cancer at University Medical Center Ho Chi Minh City. Data were extracted from a computerized database of patients who were hospitalized for lobectomy in the treatment of non-small cell lung cancer from January 2018 to December 2021. The primary outcome was the postoperative LOS.

RESULTS

Median postoperative LOS was 5.2 days (interquartile range 4.8 to 6.8 days). The complication rate was 19.2%, of which Clavien-Dindo II accounted for the highest at 9.1%. The 30-day readmission rate was 13.1%. The median of LOS in the current cigarette smoker's group was 1.9 days higher than the never-cigarette smoker's group and 1.5 days higher than the former cigarette smokers (p<0.001). Tumor-nodes-metastasis (TNM) stage III showed the highest LOS compared to other stages (p=0.029). Open surgery and thoracoscopic conversion to open showed postoperative LOS about two days longer than thoracoscopic surgery (p<0.001). ​Performing muscle relaxation and early extubation, multimodal analgesia reduced postoperative LOS by 1.6 days (p<0.001), and preoperative physical therapy and early physical therapy at recovery reduced postoperative LOS by 1.3 days (p<0.001). There was a strong positive correlation between the duration of endotracheal retention, duration of thoracic drainage, amount of blood loss, and postoperative LOS (R>0.5, p<0.001). The duration of the Post-Anesthesia Care Unit and fasting time after surgery showed an average positive correlation with postoperative LOS (0.3

CONCLUSIONS

The median postoperative LOS was 5.2 days, and more than half of patients stayed in the hospital for over five days. Some factors affect the LOS, including current cigarette smokers, TNM stage, surgical approaches, some care processes such as early extubation, multimodal pain relief, physical therapy, vomiting, duration of thoracic drainage, amount of blood loss, duration of Post-Anesthesia Care Unit (hours), duration of thoracic drainage (days), preoperative and postoperative fasting time (hours). The study results help propose many changes in perioperative care for patients undergoing lung cancer surgery.

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Key Words

• complications
• eras
• length of hospital stay
• lobectomy
• lung cancer
• vietnam

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Affiliation(s)

Ho Tat Bang Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM Health Organization and Management Department, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
Tran Thanh Vy Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM Cardiovascular and Thoracic Surgery Department, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
Nguyen Van Tap Faculty of Medical Management, Nguyen Tat Thanh University, Ho Chi Minh City, VNM

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