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Cristóbal Poch L, Cagigas Fernández C, Gómez-Ruiz M, Ortega Roldán M, Cantero Cid R, Castillo Diego J, Gómez-Fleitas M. Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections. J Robot Surg 2022; 16:575-586. [PMID: 34278544 DOI: 10.1007/s11701-021-01281-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/04/2021] [Indexed: 01/23/2023]
Abstract
Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.
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Affiliation(s)
- Lidia Cristóbal Poch
- Colorectal Surgery Unit. Hospital Universitario "Marques de Valdecilla", Av. de Valdecilla S/N, 25, 39008, Santander, Cantabria, Spain.
| | - Carmen Cagigas Fernández
- Colorectal Surgery Unit. Hospital Universitario "Marques de Valdecilla", Av. de Valdecilla S/N, 25, 39008, Santander, Cantabria, Spain
| | - Marcos Gómez-Ruiz
- Colorectal Surgery Unit. Hospital Universitario "Marques de Valdecilla", Av. de Valdecilla S/N, 25, 39008, Santander, Cantabria, Spain
- Surgical Innovation Research Group Valdecilla Biomedical Research Center, IDIVAL, Santander, Cantabria, Spain
| | - Marta Ortega Roldán
- University of Cantabria, Av de Los Castros, 39008, Santander, Cantabria, Spain
| | - Ramón Cantero Cid
- Colorectal Surgery Unit. Hospital Universitario "La Paz", Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Julio Castillo Diego
- Colorectal Surgery Unit. Hospital Universitario "Marques de Valdecilla", Av. de Valdecilla S/N, 25, 39008, Santander, Cantabria, Spain
| | - Manuel Gómez-Fleitas
- University of Cantabria, Colorectal Surgery Unit, Hospital Universitario, "Marques de Valdecilla", Av da. Valdecilla S/N, 39008, Santander, Cantabria, Spain
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Garcia LE, Taylor J, Atallah C. Update on Minimally Invasive Surgical Approaches for Rectal Cancer. Curr Oncol Rep 2021; 23:117. [PMID: 34342706 DOI: 10.1007/s11912-021-01110-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This review aims to clarify the current role of minimally invasive surgery in the treatment of rectal cancer, highlighting short- and long-term outcomes from the latest trials and studies. RECENT FINDINGS Data from previous trials has been conflicting, with some failing to demonstrate non-inferiority of laparoscopic surgical resection of rectal cancer compared to an open approach and others demonstrating similar clinical outcomes. Robot-assisted surgery was thought to be a promising solution to the challenges faced by laparoscopic surgery, and even though the only randomized controlled trial to date comparing these two techniques did not show superiority of robot-assisted surgery over laparoscopy, more recent retrospective data suggests a statistically significant higher negative circumferential resection margin rate, decreased frequency of conversion to open, and less sexual and urinary complications. Minimally invasive surgery techniques for resection of rectal cancer, particularly robot-assisted, offer clear short-term peri-operative benefits over an open approach; however, current data has yet to display non-inferiority in terms of oncological outcomes.
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Affiliation(s)
- Leonardo E Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA
| | - James Taylor
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA
| | - Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock, Baltimore, MD, 656, USA.
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Ni X, Jia D, Guo Y, Sun X, Suo J. The efficacy and safety of enhanced recovery after surgery (ERAS) program in laparoscopic digestive system surgery: A meta-analysis of randomized controlled trials. Int J Surg 2019; 69:108-115. [PMID: 31376511 DOI: 10.1016/j.ijsu.2019.07.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) program has been applied to a variety of surgeries. However, the efficacy and safety of the ERAS program in laparoscopic digestive system surgery remain unclear. We conducted a meta-analysis to evaluate the ERAS program and traditional perioperative care (TPC) in laparoscopic digestive system surgery. METHODS We searched five electronic databases for eligible trials. STATA version 14.0 and Revman version 5.3 were used to analyze the data. The results were presented and analyzed by weighted mean difference (WMD) and risk ratio (RR) at their 95% confidence interval (CI). RESULTS Twenty-five randomized controlled trials (RCTs) of 2219 patients were included in our meta-analysis. The results revealed that the postoperative hospital stay (PHS) (WMD: 2.13 day, 95% CI: 2.56 to -1.70, p = 0.000), time to first flatus (WMD: 12.68 h, 95% CI: 15.95 to -9.41, p = 0.000), and time to defecation (WMD: 34.35 h, 95% CI: 46.82 to -21.88, p = 0.000) were significantly shorter in the ERAS group compared to the TPC group. Additionally, the overall postoperative complication rate (RR: 0.66, 95% CI: 0.49 to 0.88, p = 0.000) was markedly lower in patients using the ERAS program. CONCLUSION The results indicated that the ERAS program is associated with faster postoperative rehabilitation, shorter PHS, and better postoperative complication rates. The use of the ERAS program for laparoscopic digestive system surgery is more effective and safe than TPC, and it should be recommended. (PROSPERO registration number:CRD42018118551).
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Affiliation(s)
- Xiaofei Ni
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Dan Jia
- Department of Third Operation Room, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Yuchen Guo
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Xuan Sun
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
| | - Jian Suo
- Department of Gastrointestinal Surgery, First Hospital of Jilin University, Changchun, Jilin Province, China.
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Ban KA, Gibbons MM, Ko CY, Wick EC. Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2017; 225:548-557.e3. [PMID: 28797562 DOI: 10.1016/j.jamcollsurg.2017.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Kristen A Ban
- American College of Surgeons, Chicago, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD.
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Kruse AR, Jensen TD, Lauszus FF, Kallfa E, Madsen MR. Changes in incontinence after hysterectomy. Arch Gynecol Obstet 2017; 296:783-790. [PMID: 28756528 DOI: 10.1007/s00404-017-4481-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/25/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Information about the perioperative incontinence following hysterectomy is limited. To advance the postoperative rehabilitation further we need more information about qualitative changes in incontinence, fatigue and physical function of patients undergoing hysterectomy. METHODS 108 patients undergoing planned hysterectomy were compared pre- and postoperatively. In a sub-study of the prospective follow-up study the changes in incontinence, postoperative fatigue, quality of life, physical function, and body composition were evaluated preoperatively, 13 and 30 days postoperatively. Sample size calculation indicated that 102 women had to be included. The incontinence status was estimated by a Danish version of the ICIG questionnaire; further, visual analogue scale, dynamometer for hand grip, knee extension strength and balance were applied. Work capacity was measured ergometer cycle together with lean body mass by impedance. Quality of life was assessed using the SF-36 questionnaire. Patients were examined preoperatively and twice postoperatively. RESULTS In total 41 women improved their incontinence after hysterectomy and 10 women reported deterioration. Preoperative stress incontinence correlated with BMI (r = 0.25, p < 0.01) and urge incontinence with age (r = 0.24, p < 0.02). Further, improvement after hysterectomy in stress incontinence was associated with younger age (r = 0.20, p < 0.04). Improvement in urge incontinence was positively associated with BMI (r = 0.22, p = 0.02). A slight but significant loss was seen in lean body mass 13 and 30 days postoperatively. CONCLUSIONS Hysterectomy was not significantly associated with the risk of incontinence; in particular, when no further vaginal surgery is performed. Hysterectomy may even have a slightly positive effect on incontinence and de-novo cure.
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Affiliation(s)
- Anne Raabjerg Kruse
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
| | | | - Finn Friis Lauszus
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark.
| | - Ervin Kallfa
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
| | - Mogens Rørbæk Madsen
- Surgical Research Unit, Department of Surgery, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
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Curtis NJ, Noble E, Salib E, Hipkiss R, Meachim E, Dalton R, Allison A, Ockrim J, Francis NK. Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival? Colorectal Dis 2017; 19:723-730. [PMID: 28093901 DOI: 10.1111/codi.13603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/28/2016] [Indexed: 02/08/2023]
Abstract
AIM Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes. METHOD A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission. RESULTS A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P = 0.092), but OS was worse in patients with longer total LoS (20 vs 14 days, P = 0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission. CONCLUSION Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.
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Affiliation(s)
- N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Noble
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Salib
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - R Hipkiss
- Information Management Team, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - E Meachim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - R Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - A Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - J Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - N K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK.,Faculty of Science, University of Bath, Bath, UK
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Reduced 30-Day Mortality After Laparoscopic Colorectal Cancer Surgery: A Population Based Study From the Dutch Surgical Colorectal Audit (DSCA). Ann Surg 2017; 264:135-40. [PMID: 27272958 DOI: 10.1097/sla.0000000000001412] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the impact of a laparoscopic resection on postoperative mortality after colorectal cancer surgery. BACKGROUND The question whether laparoscopic resection (LR) compared with open surgery [open resection (OR)] for colorectal cancer influences the risk of postoperative mortality remains unresolved. Several meta-analyses showed a trend but failed to reach statistical significance. The exclusion of high-risk patients and insufficient power might be responsible for that. We analyzed the influence of LR on postoperative mortality in a risk-stratified comparison and secondly, we studied the effect of LR on postoperative morbidity. METHODS Data from the Dutch Surgical Colorectal Audit (2010-2013) were used. Homogenous subgroups of patients were defined on the basis of factors influencing the choice of surgical approach and risk factors for postoperative mortality. Crude mortality rates were compared between LR and OR. The influence of LR on postoperative complications was evaluated using both univariable and multivariable analyses. RESULTS In patients undergoing elective surgery for nonlocally advanced, nonmetastasized colon cancer, LR was associated with a significant lower risk of postoperative mortality than OR in 20/22 subgroups. LR was independently associated with a lower risk of cardiac (odds ratio: 0.73, 95% confidence interval: 0.66-0.82) and respiratory (odds ratio: 0.73, 95% confidence interval: 0.64-0.84) complications. CONCLUSIONS LR reduces the risk of postoperative mortality compared with OR in elective setting in patients with nonlocally advanced, nonmetastasized colorectal cancer. Especially elderly frail patients seem to benefit because of reduced cardiopulmonary complications. These findings support widespread implementation of LR for colorectal cancer also in patients at high operative risk.
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Are we ready for the ERAS protocol in colorectal surgery? Wideochir Inne Tech Maloinwazyjne 2017; 12:7-12. [PMID: 28446926 PMCID: PMC5397552 DOI: 10.5114/wiitm.2017.66672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/02/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Modern perioperative care principles in elective colorectal surgery have already been established by international surgical authorities. Nevertheless, barriers to the introduction of routine evidence-based clinical care and changing dogmas still exist. One of the factors is the surgeon. Aim To assess perioperative care trends in elective colorectal surgery among general surgery consultants in surgical departments in Malopolska Voivodeship, Poland. Material and methods An anonymous standardized 20-question questionnaire was developed based on ERAS principles and sent out to Malopolska Voivodeship general surgery departments. Answers of general surgery consultants showed the level of acceptance of elements of perioperative care. Results The overall response rate was 66%. Several elements (antibiotic and antithrombotic prophylaxis, postoperative oxygen therapy, no nasogastric tubes) had quite a high acceptance rate. On the other hand, most crucial surgical perioperative elements (lack of mechanical bowel preparation, preoperative oral carbohydrate loading, use of laparoscopy and lack of drains, early fluid and oral diet intake, early mobilization) were not followed according to evidence-based ERAS protocol recommendations. Surgeons were not willing to change their practice, but were supportive of changes in anesthesiologist-dependent elements of perioperative care, such as restrictive fluid therapy, use of transversus abdominis plane blocks, etc. Conclusions Many elements of perioperative care in elective colorectal surgery in Malopolska Voivodeship are still dictated by dogma and are not evidence-based. The level of acceptance of many important ERAS protocol elements is low. Surgeons are ready to accept only changes that do not interfere with their practice.
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Rentsch M, Schiergens T, Khandoga A, Werner J. Surgery for Colorectal Cancer - Trends, Developments, and Future Perspectives. Visc Med 2016; 32:184-91. [PMID: 27493946 DOI: 10.1159/000446490] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although colorectal surgery is long established as the mainstay treatment for colon cancer, certain topics regarding technical fine-tuning to increase postsurgical recurrence-free survival have remained a matter of debate throughout the past years. These include complete mesocolic excision (CME), treatment strategies for metastatic disease, significance of hyperthermic intraperitoneal chemotherapy (HIPEC), and surgical techniques for the treatment of colorectal cancer recurrence. In addition, new surgical techniques have been introduced in oncologic colorectal surgery, and their potential to provide sufficiently radical resection has yet to be proven. METHODS A structured review of the literature was performed to identify the current state of the art with regard to the mentioned key issues in colorectal surgery. RESULTS This article provides a comprehensive review of the current literature addressing the above-mentioned current challenges in colorectal surgery. The focus lies on the impact of CME and, in relation to this, on lymph node dissection, as well as on treatment of metastatic disease including peritoneal spread, and finally on the treatment of recurrent disease. CONCLUSION Uniformly, the current literature reveals that surgery aiming at complete malignancy elimination within multimodal treatment approaches represents the fundamental quantum leap for the achievement of long-term tumor-free survival.
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Affiliation(s)
- Markus Rentsch
- Department of General, Visceral, Transplantation Surgery, University of Munich, Campus Großhadern, Munich, Germany
| | - Tobias Schiergens
- Department of General, Visceral, Transplantation Surgery, University of Munich, Campus Großhadern, Munich, Germany
| | - Andrej Khandoga
- Department of General, Visceral, Transplantation Surgery, University of Munich, Campus Großhadern, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Transplantation Surgery, University of Munich, Campus Großhadern, Munich, Germany
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Harrison OJ, Smart NJ, White P, Brigic A, Carlisle ER, Allison AS, Ockrim JB, Francis NK. Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. JSLS 2016; 18:265-72. [PMID: 24960491 PMCID: PMC4035638 DOI: 10.4293/108680813x13753907291918] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives: Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. Methods: Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days). Results: Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05–3.90; P = .027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501–6.462, P = .002). Conclusions: Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.
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Affiliation(s)
- Oliver J Harrison
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, Somerset BA21 4AT, UK.
| | - Neil J Smart
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
| | - Paul White
- University of the West of England, Bristol, UK
| | - Adela Brigic
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
| | - Elinor R Carlisle
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
| | - Andrew S Allison
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
| | - Jonathan B Ockrim
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital, Yeovil, Somerset, UK
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Zhao JH, Sun JX, Huang XZ, Gao P, Chen XW, Song YX, Liu J, Cai CZ, Xu HM, Wang ZN. Meta-analysis of the laparoscopic versus open colorectal surgery within fast track surgery. Int J Colorectal Dis 2016; 31:613-22. [PMID: 26732262 DOI: 10.1007/s00384-015-2493-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laparoscopic methods and fast-track surgery (FTS) can enhance recovery and reduce postoperative hospital stay. However, whether laparoscopic surgery can provide short-term benefits within FTS is controversial. Thus, we conducted a meta-analysis of published studies to evaluate the effect of laparoscopic colorectal surgery within FTS. METHODS We searched PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies. Endpoints were duration of postoperative hospital stay, time to first bowel movement, total postoperative complication rate, readmission rate, mortality within 30 days after surgery, and conversation rate of laparoscopic surgery. RESULTS Four randomized controlled trials and six clinical controlled trials (1510 patients) were eligible for analyses. Duration of postoperative hospital stay (weighted mean difference, -1.65 days; p < 0.001), time to first bowel movement (-1.13 days; p < 0.001), total postoperative complication rate (risk ratio [RR], 0.65; p < 0.001), readmission rate (0.46; p < 0.001), and mortality (0.45; p < 0.001) were significantly reduced in the laparoscopic surgery group. Overall conversion rate of laparoscopic surgery was 11.1%. Subgroup analyses based on each FT element demonstrated that studies without the element "prevention of hypothermia," "no bowel preparation," or "no routine use of drains" did not show significant differences between two groups with regard to duration of postoperative hospital stay or total prevalence of postoperative complications. CONCLUSION Within FTS, laparoscopic methods can significantly shorten postoperative hospital stay, accelerate postoperative recovery, and enhance safety in colorectal surgery. The FT elements "prevention of hypothermia," "no bowel preparation," and "no routine use of drains" may play important parts in the combined effect of these two methods.
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Affiliation(s)
- Jun-hua Zhao
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jing-xu Sun
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xuan-zhang Huang
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Xiao-wan Chen
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Yong-xi Song
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Jing Liu
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Cheng-zhe Cai
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Hui-mian Xu
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
| | - Zhen-ning Wang
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, 110001, People's Republic of China.
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Fatigue and physical function after hysterectomy measured by SF-36, ergometer, and dynamometer. Arch Gynecol Obstet 2016; 294:95-101. [DOI: 10.1007/s00404-015-3999-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
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Kehlet H, Joshi GP. Systematic Reviews and Meta-Analyses of Randomized Controlled Trials on Perioperative Outcomes: An Urgent Need for Critical Reappraisal. Anesth Analg 2015; 121:1104-1107. [PMID: 26378707 DOI: 10.1213/ane.0000000000000687] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Henrik Kehlet
- From the *Department for Surgical Pathophysiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark; and †Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Rink AD, Vestweber B, Hahn J, Alfes A, Paul C, Vestweber KH. Single-incision laparoscopic surgery for diverticulitis in overweight patients. Langenbecks Arch Surg 2015; 400:797-804. [PMID: 26283162 DOI: 10.1007/s00423-015-1333-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 08/05/2015] [Indexed: 12/26/2022]
Abstract
AIM Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy. METHODS From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)). RESULTS The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups. CONCLUSION Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.
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Affiliation(s)
- Andreas D Rink
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany.
| | - Boris Vestweber
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany.,King Edward VII Memorial Hospital, PO-Box HM 1023, Hamilton HM DX, Bermuda
| | - Jasmina Hahn
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany
| | - Angelika Alfes
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany
| | - Claudia Paul
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany
| | - Karl-Heinz Vestweber
- Department of General, Visceral, and Thoracic Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany
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Ni TG, Yang HT, Zhang H, Meng HP, Li B. Enhanced recovery after surgery programs in patients undergoing hepatectomy: A meta-analysis. World J Gastroenterol 2015; 21:9209-9216. [PMID: 26290648 PMCID: PMC4533053 DOI: 10.3748/wjg.v21.i30.9209] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/19/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of enhanced recovery after surgery (ERAS) programs in comparison with traditional care on liver surgery outcomes.
METHODS: The PubMed, EMBASE, CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria: (1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery; (2) outcome measures including complications, recovery of bowel function, and hospital length of stay; and (3) RCTs. The following exclusion criteria were applied: (1) the study was not an RCT; (2) the study did not compare ERAS with traditional care; (3) the study reported on emergency, non-elective or transplantation surgery; and (4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.
RESULTS: Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases, patients presented with benign diseases, while the remaining 713 cases had liver cancer. Of the five studies, three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group, while 369 patients were in the traditional care group. Compared with traditional care, ERAS programs were associated with significantly decreased overall complications (RR = 0.66; 95%CI: 0.49-0.88; P = 0.005), grade I complications (RR = 0.51; 95%CI: 0.33-0.79; P = 0.003), and hospital length of stay [WMD = -2.77 d, 95%CI: -3.87-(-1.66); P < 0.00001]. Similarly, ERAS programs were associated with decreased time to first flatus [WMD = -19.69 h, 95%CI: -34.63-(-4.74); P < 0.0001]. There was no statistically significant difference in grade II-V complications between the two groups.
CONCLUSION: ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.
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Lei QC, Wang XY, Zheng HZ, Xia XF, Bi JC, Gao XJ, Li N. Laparoscopic Versus Open Colorectal Resection Within Fast Track Programs: An Update Meta-Analysis Based on Randomized Controlled Trials. J Clin Med Res 2015; 7:594-601. [PMID: 26124904 PMCID: PMC4471745 DOI: 10.14740/jocmr2177w] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 12/20/2022] Open
Abstract
The objective of the study was to assess the safety and efficacy of laparoscopic colorectal surgery by comparing open operation within fast track (FT) programs. The Cochrane Library, PubMed, Embase and Chinese Biological Medicine Database were searched to identify all available randomized controlled trials (RCTs) comparing laparoscopic with open colorectal resection within FT programs. A total of seven RCTs were finally included, enrolling 714 patients with colorectal cancer: 373 patients underwent laparoscopic surgery and FT programs (laparoscopic/FT group) and 341 patients received open operation and FT programs (open/FT group). Postoperative hospital stay (weighted mean difference (WMD): 0.66; 95% CI: 0.27 - 1.04; P < 0.05), total hospital stay (WMD: 1.46; 95% CI: 0.40 - 2.51; P < 0.05) and overall complications (RR: 1.31; 95% CI: 1.12 - 1.54; P < 0.05) were significantly lower in laparoscopic/FT group than in open/FT group. However, no statistically significant differences on mortality (risk ratio (RR): 2.26; 95% CI: 0.62 - 8.22; P = 0.21), overall surgical complications (RR: 1.19; 95% CI: 0.94 - 1.51; P = 0.15) and readmission rates (RR: 1.33; 95% CI: 0.79 - 2.22; P = 0.28) were found between both groups. The laparoscopic colorectal surgery combined with FT programs shows high-level evidence on shortening postoperative and total hospital stay, reducing overall complications without compromising patients’ safety.
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Affiliation(s)
- Qiu-Cheng Lei
- Department of General Surgery, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Xin-Ying Wang
- Department of General Surgery, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, China ; Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Hua-Zhen Zheng
- Key Laboratory for Medical Molecular Diagnostics of Guangdong Province, Guangdong Medical College, Dongguan, Guangdong Province, China
| | - Xian-Feng Xia
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, the Chinese University of Hong Kong, China
| | - Jing-Cheng Bi
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Xue-Jin Gao
- Department of General Surgery, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, China
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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A Systematic Review of Economic Evaluations of Enhanced Recovery Pathways for Colorectal Surgery. Ann Surg 2015; 261:e138. [DOI: 10.1097/sla.0000000000000679] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Reduced perioperative death following laparoscopic colorectal resection: results of an international observational study. Surg Endosc 2015; 29:3628-39. [PMID: 25761553 DOI: 10.1007/s00464-015-4119-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic approaches to colorectal surgery are known to accelerate recovery but the effect on postoperative mortality is uncertain. The purpose of this study was to determine whether differences exist in postoperative mortality between patients undergoing laparoscopic and open colorectal surgery in a group of international healthcare institutions. METHODS Administrative data from 30 worldwide institutions were searched for patients who underwent elective colorectal surgical resection between January 2007 and December 2011. The primary outcome measure was 30-day-in-hospital mortality rate. Secondary outcome measures were 30-day readmission rate, length of stay, and 30-day reoperation rate. RESULTS There were 30,369 (20,641 colonic and 9728 rectal) resections recorded over the 5 years. Eight thousand eighty-six were laparoscopic (26.6%) and 22,283 (73.4%) were open. Following propensity-score matching of the laparoscopic and open cohorts, mortality was 0.5% following laparoscopic colectomy and 1.2% after conventional surgery (P < 0.001). After adjusting for differences in preoperative risk factors including gender, age, comorbidity, type of surgery and diagnosis, by matching on propensity score, laparoscopic surgery was a strong determinant of reduced 30-day mortality (odds ratio 0.44; 95% confidence interval 0.31-0.62; P < 0.001), reduced hospital stay (odds ratio 0.42, 95% confidence interval 0.39-0.45; P < 0.001), reduced readmission (odds ratio 0.78, 95% confidence interval 0.71-0.86; P < 0.001) and reduced re-operation (odds ratio 0.75, 95% confidence interval 0.65-0.76; P < 0.001). CONCLUSIONS Minimally invasive colorectal surgery is associated with reduced in-hospital mortality when compared with conventional techniques. This finding is consistent across international healthcare institutions and supports efforts to disseminate laparoscopic skills.
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Lei Q, Wang X, Tan S, Xia X, Zheng H, Wu C. Fast-track programs versus traditional care in hepatectomy: a meta-analysis of randomized controlled trials. Dig Surg 2014; 31:392-9. [PMID: 25547153 DOI: 10.1159/000369219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/19/2014] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS The role of fast-track programs in hepatectomy is unclear. This meta-analysis aimed to evaluate the efficacy and safety of fast-track programs versus traditional care. METHODS We searched Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar for relevant randomized controlled trials (RCTs) comparing fast-track with traditional care in hepatectomy. Length of hospital stay, time to first flatus, postoperative complications, operating time, and intraoperative blood loss were assessed. Meta-analyses were performed using RevMan 5.2 software. RESULTS Four original RCTs with 372 patients were included: 187 in the fast-track and 185 in the traditional care group. Fast-track patients had shorter hospital stay (WMD -2.32; 95% CI, -3.54 to -1.11; p < 0.001) and time to first flatus (WMD -0.99; 95% CI, -1.15 to -0.84; p < 0.001), and less postoperative complications (RR 0.66; 95% CI, 0.47 to 0.93; p < 0.05). However, there was significant heterogeneity between the studies regarding hospital stay (I(2) = 88%; p < 0.001). Operating time and intraoperative blood loss were not different. CONCLUSIONS Patients in fast-track programs had less time to first flatus and postoperative complications compared to traditional care. Fast-track programs may reduce the length of hospital stay. Larger, higher quality prospective RCTs are necessary to draw more robust conclusions.
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Affiliation(s)
- Qiucheng Lei
- Department of General Surgery, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, China
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Chand M, Siddiqui MRS, Gupta A, Rasheed S, Tekkis P, Parvaiz A, Mirnezami AH, Qureshi T. Systematic review of emergent laparoscopic colorectal surgery for benign and malignant disease. World J Gastroenterol 2014; 20:16956-63. [PMID: 25493008 PMCID: PMC4258564 DOI: 10.3748/wjg.v20.i45.16956] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/31/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic surgery has become well established in the management of both and malignant colorectal disease. The last decade has seen increasing numbers of surgeons trained to a high standard in minimally-invasive surgery. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. There is a perception that emergent surgery is technically more difficult and may lead to worse outcomes. The present review aims to provide a comprehensive and critical appraisal of the available literature on the use of laparoscopic colorectal surgery (LCS) in the emergency setting. The literature is broadly divided by the underlying pathology; that is, inflammatory bowel disease, diverticulitis and malignant obstruction. There were no randomized trials and the majority of the studies were case-matched series or comparative studies. The overall trend was that LCS is associated with shorter hospital stay, par or fewer complications but an increased operating time.Emergency LCS can be safely undertaken for both benign and malignant disease providing there is appropriate patient selection, the surgeon is adequately experienced and there are sufficient resources to allow for a potentially more complex operation.
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Ehrlich A, Kellokumpu S, Wagner B, Kautiainen H, Kellokumpu I. Comparison of laparoscopic and open colonic resection within fast-track and traditional perioperative care pathways: Clinical outcomes and in-hospital costs. Scand J Surg 2014; 104:211-8. [PMID: 25384909 DOI: 10.1177/1457496914557016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study examined short-term clinical outcomes and in-hospital costs of laparoscopic and open colonic resection within fast-track and traditional care pathways. MATERIAL AND METHODS A case-control study was performed. From 2007 to 2009, 116 patients underwent laparoscopic or open colonic resection for benign or malignant disease within fast-track care pathway. The control group consisted of 116 age-, sex-, comorbidity-, type of surgery-, and diagnosis-matched patients who received a traditional perioperative care from 2000 to 2007. The main measures of outcome were postoperative hospital stay and in-hospital costs, with 30-day mortality, morbidity, reoperation, and readmission rates as secondary outcomes. RESULTS The study groups were well balanced for baseline characteristics. Postoperative hospital stay was shorter in the fast-track than in the control group: laparoscopic resection median 3 versus 5 days (p < 0.001) and open resection 4 versus 7 days (p < 0.001). In multivariate analysis fast-track care, laparoscopic surgery and complications were independent determinants affecting the length of hospital stay. Overall, there was a trend toward lower in-hospital costs in the fast-track group compared with the traditional care group, but the difference was not statistically significant. Open surgery within fast-track care was the least costly option compared to laparoscopic or open surgery within traditional care but not significantly so when compared with laparoscopy within fast-track care. Intake of solid food and bowel function recovered 1 day earlier in the fast-track group than in the control group (p < 0.001). Complications were more frequent after open surgery than after laparoscopic surgery (23.3% vs 11.0%, p = 0.012). Reoperation and readmission rates were similar between the study groups. CONCLUSION Laparoscopy improves the efficiency of fast-track perioperative care without significantly increasing in-hospital costs.
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Affiliation(s)
- A Ehrlich
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - S Kellokumpu
- Jyväskylä University School of Business and Economics, Jyväskylä, Finland
| | - B Wagner
- Department of Anesthesiology, Central Hospital of Central Finland, Jyväskylä, Finland
| | - H Kautiainen
- Department of General Practice, Primary Health Care Unit, Turku University Hospital, Turku, Finland Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
| | - I Kellokumpu
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
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Paton F, Chambers D, Wilson P, Eastwood A, Craig D, Fox D, Jayne D, McGinnes E. Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BackgroundThere has been growing interest in the NHS over recent years in the use of enhanced recovery programmes for elective surgery to deliver productivity gains through reduced length of stay, fewer postoperative complications, reduced readmissions and improved patient outcomes.ObjectivesTo evaluate the clinical effectiveness and cost-effectiveness of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings. To identify and critically describe key factors associated with successful adoption, implementation and sustainability of enhanced recovery programmes in UK settings. To summarise existing knowledge about patient experience of enhanced recovery programmes in UK settings.Data sourcesEight databases, including Database of Abstracts of Reviews and Effects, International Prospective of Systematic Reviews, NHS Economic Evaluation Database and MEDLINE, were searched from 1990 to March 2013 without language restrictions. Relevant reports and guidelines and reference lists of retrieved articles were scanned to identify additional studies.Review methodsSystematic reviews, randomised controlled trials (RCTs), economic evaluations, and UK NHS cost analysis studies were included if they evaluated the impact of enhanced recovery programmes on any health- and cost-related outcomes. Eligible studies included patients undergoing elective surgery in an acute hospital setting. Implementation case studies and surveys of patient experience in a UK setting were also eligible for inclusion. Quality assessment of systematic reviews, RCTs and economic evaluations was based on existing Centre for Reviews and Dissemination processes. All stages of the review process were performed by one researcher and checked by a second with discrepancies resolved by consensus. The type and range of evidence precluded meta-analysis and we therefore performed a narrative synthesis, differentiating between clinical effectiveness and cost-effectiveness, implementation case studies and evidence on patient experience.ResultsSeventeen systematic reviews of varying quality were included in this report. Twelve additional RCTs were included; all were considered at high risk of bias. Most of the evidence focused on colorectal surgery. Fourteen innovation case studies and 15 implementation case studies undertaken in NHS settings were identified and provide descriptions of factors critical to the success of an enhanced recovery programme. Ten relevant economic evaluations were identified evaluating costs and outcomes over short time horizons. Despite the plethora of studies, robust evidence was sparse. Evidence for colorectal surgery suggests that enhanced recovery programmes may reduce hospital stays by 0.5–3.5 days compared with conventional care. There were no significant differences in reported readmission rates. Other surgical specialties showed greater variation in reported reductions in length of stay reflecting the limited evidence identified.LimitationsFindings relating to other clinical outcomes, cost-effectiveness, implementation and patient experience were hampered by a lack of robust evidence and poor reporting.ConclusionsThere is consistent, albeit limited, evidence that enhanced recovery programmes may reduce length of patient hospital stay without increasing readmission rates. The extent to which managers and clinicians considering implementing enhanced recovery programmes can realise reductions and cost savings will depend on length of stays achieved under their existing care pathway. RCTs comparing an enhanced recovery programme with conventional care continue to be conducted and published. Further single-centre RCTs of this kind are not a priority. Rather, what is needed is improved collection and reporting of how enhanced recovery programmes are implemented, resourced and experienced in NHS settings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Fiona Paton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Duncan Chambers
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Paul Wilson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Alison Eastwood
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Dawn Craig
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Dave Fox
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Jayne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Arezzo A, Passera R, Scozzari G, Verra M, Morino M. Laparoscopy for extraperitoneal rectal cancer reduces short-term morbidity: Results of a systematic review and meta-analysis. United European Gastroenterol J 2014; 1:32-47. [PMID: 24917939 DOI: 10.1177/2050640612473753] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 12/12/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The role of laparoscopy in the treatment of extraperitoneal rectal cancer is still controversial. The aim of the study was to evaluate differences in safety of laparoscopic rectal resection for extraperitoneal cancer, compared with open surgery. MATERIALS AND METHODS A systematic review from 2000 to July 2012 was performed searching the MEDLINE and EMBASE databases (PROSPERO registration number CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30-day mortality and morbidity. Then a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect. RESULTS Eleven studies, representing 1684 patients, met the inclusion criteria: four were randomized for a total of 814 patients. Mortality was observed in 1.2% of patients in the laparoscopic group and in 2.3% of patients in the open group, with an RR of 0.56 (95% CI 0.19-1.64, p = 0.287). The overall incidence of short-term complications was lower in the laparoscopic group (31.5%) compared to the open group (38.2%), with an RR of 0.83 (95% CI 0.73-0.94, p = 0.004). Surgical complications, wound complications, blood loss and the need for blood transfusion, time for bowel movement recovery, food intake recovery, and hospital stay were significantly lower or less frequent in the laparoscopic group. The incidence of intra-operative injuries, anastomotic leakages, and surgical re-interventions was similar in the two groups. Only operative time was in favour of the open group. CONCLUSIONS Based on the evidence of both randomized and prospective controlled series, mortality was lower after laparoscopy although not significantly so, while the short-term morbidity RR, including subgroup analysis, was significantly lower after laparoscopy for extraperitoneal rectal cancer compared to open surgery.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Turin, Turin, Italy
| | - Gitana Scozzari
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mauro Verra
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Turin, Turin, Italy
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Laparoscopy-assisted transvaginal resection of sigmoid cancer. Eur J Surg Oncol 2014; 40:713-8. [DOI: 10.1016/j.ejso.2014.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/13/2013] [Accepted: 01/13/2014] [Indexed: 01/26/2023] Open
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Odermatt M, Miskovic D, Siddiqi N, Khan J, Parvaiz A. Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study. World J Surg 2014; 37:2458-67. [PMID: 23846176 DOI: 10.1007/s00268-013-2146-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies. METHODS The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan-Meier curves. RESULTS During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3-4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35-76) in the laparoscopic group versus 43 % (95 % CI 32-58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20-60) versus 37 % (95 % CI 27-50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy. CONCLUSIONS Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.
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Affiliation(s)
- Manfred Odermatt
- Minimally Invasive Colorectal Unit (MICRU), Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth, PO6 3LY, UK.
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Nanavati AJ, Prabhakar S. A comparative study of 'fast-track' versus traditional peri-operative care protocols in gastrointestinal surgeries. J Gastrointest Surg 2014; 18:757-67. [PMID: 24222323 DOI: 10.1007/s11605-013-2403-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 10/22/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A 'fast-track protocol' in surgery suggests the application of evidence-based practices to expedite patient recovery. It has shown to reduce hospital stay, hasten recovery as well as facilitate earlier return to work. It has a considerable impact in reducing healthcare costs. The basic tenet is to treat the patient's disease by minimal disturbance of their physiology. The protocol encompasses pre-operative, intra-operative and post-operative interventions which when carried out together would show maximal benefits. The surgeon is usually the leader of the team managing the patient, but it cannot be over-emphasised that this is a multi-disciplinary team approach. MATERIALS AND METHODS We conducted a prospective interventional study to investigate whether 'fast-track' surgery protocols improve patient outcome when compared to traditional peri-operative care followed at our institute. By doing so, we observed that the patients who underwent 'fast tracking' required lesser analgesia, had earlier ambulation, earlier return of intestinal motility, were free from tubes, catheters and drains earlier and lastly were discharged earlier. This was achieved without a rise in complications or re-admissions. RESULTS/CONCLUSION The results have proved that implementing the fast-track protocol for gastrointestinal surgeries is not only safe and effective, but also improves patient outcome.
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Affiliation(s)
- Aditya J Nanavati
- Department of General Surgery, L.T.M.G.H., Eastern Expressway, Sion, Mumbai, 400022, India,
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The aetiology of delay to commencement of adjuvant chemotherapy following colorectal resection. Int J Surg Oncol 2014; 2014:670212. [PMID: 24757562 PMCID: PMC3976919 DOI: 10.1155/2014/670212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 02/12/2014] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Timely administration of adjuvant chemotherapy following colorectal resection is associated with improved outcome. We aim to assess the factors which are associated with delay to adjuvant chemotherapy in patients who underwent colorectal resection as part of an enhanced recovery protocol. METHOD A univariate and multivariate analysis of patient data collected as part of a prospectively maintained database of colorectal cancer patients between 2007 and 2012. RESULTS 166 patients underwent colorectal resection followed by adjuvant chemotherapy. Median postoperative hospital stay was 6 days, and time to commencement of adjuvant chemotherapy was 50 days. Longer inpatient stay correlated with increased time to adjuvant chemotherapy (P = 0.05). Factors found to be independently associated with duration of hospital stay and time to commencement of adjuvant chemotherapy included stoma formation (P = 0.032), anastaomotic leak (P = 0.027), and preoperative albumin (P = 0.027). The use of laparoscopic surgery was associated with shorter time to adjuvant chemotherapy but did not reach significance (P = 0.143). CONCLUSION A number of independent variables associated with delay to adjuvant therapy previously not described have been identified. Further work may be required to elucidate the effect that these variables have on long-term outcome.
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Esteban F, Cerdan FJ, Garcia-Alonso M, Sanz-Lopez R, Arroyo A, Ramirez JM, Moreno C, Morales R, Navarro A, Fuentes M. A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery. Colorectal Dis 2014; 16:134-40. [PMID: 24164975 DOI: 10.1111/codi.12472] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023]
Abstract
AIM The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period. METHOD A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates. RESULTS The overall median HS was 7 days. The median HS for laparoscopy + FT was 5 days, open + FT 6 days, laparoscopy + CC 9 days and open + CC 10 days (P < 0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P < 0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P < 0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points. CONCLUSION Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.
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Affiliation(s)
- F Esteban
- Hospital Clinico San Carlos, Madrid, Spain
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Chen ZX, Liu AHJ, Cen Y. Fast-track program vs traditional care in surgery for gastric cancer. World J Gastroenterol 2014; 20:578-583. [PMID: 24574728 PMCID: PMC3923034 DOI: 10.3748/wjg.v20.i2.578] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review the evidence for the effectiveness of fast-track program vs traditional care in laparoscopic or open surgery for gastric cancer.
METHODS: PubMed, Embase and the Cochrane library databases were electronically searched for published studies between January 1995 and April 2013, and only randomized trials were included. The references of relevant studies were manually searched for further studies that may have been missed. Search terms included “gastric cancer”, “fast track” and “enhanced recovery”. Five outcome variables were considered most suitable for analysis: postoperative hospital stay, medical cost, duration to first flatus, C-reactive protein (CRP) level and complications. Postoperative hospital stay was calculated from the date of operation to the date of discharge. Fixed effects model was used for meta-analysis.
RESULTS: Compared with traditional care, fast-track program could significantly decrease the postoperative hospital stay [weighted mean difference (WMD) = -1.19, 95%CI: -1.79--0.60, P = 0.0001, fixed model], duration to first flatus (WMD = -6.82, 95%CI: -11.51--2.13, P = 0.004), medical costs (WMD = -2590, 95%CI: -4054--1126, P = 0.001), and the level of CRP (WMD = -17.78, 95%CI: -32.22--3.35, P = 0.0001) in laparoscopic surgery for gastric cancer. In open surgery for gastric cancer, fast-track program could also significantly decrease the postoperative hospital stay (WMD = -1.99, 95%CI: -2.09--1.89, P = 0.0001), duration to first flatus (WMD = -12.0, 95%CI: -18.89--5.11, P = 0.001), medical cost (WMD = -3674, 95%CI: -5025--2323, P = 0.0001), and the level of CRP (WMD = -27.34, 95%CI: -35.42--19.26, P = 0.0001). Furthermore, fast-track program did not significantly increase the incidence of complication (RR = 1.39, 95%CI: 0.77-2.51, P = 0.27, for laparoscopic surgery; and RR = 1.52, 95%CI: 0.90-2.56, P = 0.12, for open surgery).
CONCLUSION: Our overall results suggested that compared with traditional care, fast-track program could result in shorter postoperative hospital stay, less medical costs, and lower level of CRP, with no more complications occurring in both laparoscopic and open surgery for gastric cancer.
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Risk factors for readmission after elective colectomy: postoperative complications are more important than patient and operative factors. Dis Colon Rectum 2014; 57:98-104. [PMID: 24316952 DOI: 10.1097/dcr.0000000000000007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colon resections are associated with substantial risk for morbidity and readmissions, and these have become markers for quality of care. OBJECTIVE The purpose of this study was to determine risk factors for readmissions after elective colectomies to improve patient care and better understand the complex issues associated with readmissions. DESIGN This was an analysis of the prospective, statewide, multicenter Michigan Surgical Quality Collaborative database. SETTINGS The analysis was conducted at academic and community medical centers in the state of Michigan. PATIENTS Elective laparoscopic and open ileocolic and segmental colectomies from 2008 through 2010 were included. MAIN OUTCOME MEASURES Univariate analysis and a multivariate logistic regression model were used to determine influence of patient characteristics, operative factors, and postoperative complications on the incidence of 30-day postoperative readmission. RESULTS The readmission rate among 4013 cases was 7.3% (N = 293). On the basis of multivariate logistic regression, the top 3 significant risk factors associated with readmission were stroke (OR, 10.0 [95% CI, 2.70-37.0]; p = 0.001), venous thromboembolism (OR, 6.5 [95% CI, 3.7-11.3]; p < 0.0001), and organ-space surgical site infection (OR, 5.6 [95% CI, 3.4-9.4]; p < 0.0001). Important factors that contributed to readmission risk but were not found to be independent predictors of readmission included diabetes mellitus, preoperative steroids, smoking, cardiac comorbidities, age >80 years, anastomotic leaks, fascial dehiscence, sepsis, pneumonia, unplanned intubation, and length of stay. LIMITATIONS The Michigan Surgical Quality Collaborative is a large database, and true causal relations are difficult to determine; reason for readmission is not recorded in the database. CONCLUSIONS Postoperative complications account for the majority of risk factors behind readmissions after elective colectomy, whereas preoperative risk factors have less direct influence. Current strategies addressing readmission rates should focus on reducing preventable complications.
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Li S, Liu Y, Peng Q, Xie L, Wang J, Qin X. Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials. J Gastroenterol Hepatol 2013; 28:1122-32. [PMID: 23551339 DOI: 10.1111/jgh.12206] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIM Chewing gum proposal has been used in surgery to reduce postoperative ileus for more than 10 years; however, the efficacy remains imprecise. The aim of this study was to accurately assess whether the use of the chewing gum could reduce duration of postoperative ileus following the abdominal surgery. METHODS A systematic review was conducted in Medline, EMBASE, and the Cochrane Library through December 2012 to identify randomized controlled trials comparing with and without the use of chewing gum in patients undergoing abdominal surgery. The outcome of interest was time to flatus, time to bowel movement, and length of stay. Subgroup analyses were performed to examine the impact of different studies structural design. Cumulative meta-analyses were used to examine how the evidence has changed over time. RESULTS Seventeen randomized controlled trials involving 1374 participants were included. Overall time (in days) for the patients to pass flatus (weighted mean difference [WMD], -0.31; 95% confidence interval [CI], -0.43 to -0.19; P = 0.000); time to bowel movement (WMD, -0.51; 95% CI, -0.73 to -0.29; P = 0.000); and length of stay (WMD, -0.72; 95% CI, -1.02 to -0.43; P = 0.000) were significantly reduced in the treatment group. However, both of these results demonstrated significant heterogeneity. No evidence of publication bias was observed. Cumulative meta-analysis showed that chewing gum reduces duration of postoperative ileus that has been available for over 6 years. CONCLUSIONS Results of the meta-analysis suggest that chewing gum following abdominal surgery offers benefits in reducing the time of postoperative ileus.
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Affiliation(s)
- Shan Li
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China.
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Harris CA, Sharma P, Frizelle FA. Laparoscopic colorectal cancer surgery: panacea, placebo or just good fun? Expert Rev Gastroenterol Hepatol 2013; 7:393-5. [PMID: 23899276 DOI: 10.1586/17474124.2013.811035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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