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Yuan CD, Zhou BZ, Wang NY, Wan QQ, Hu ZZ. Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery. World J Gastroenterol 2025; 31:102331. [DOI: 10.3748/wjg.v31.i8.102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2024] [Revised: 12/11/2024] [Accepted: 01/14/2025] [Indexed: 01/23/2025] Open
Abstract
BACKGROUND Although the 2021 Chinese Clinical Practice Guidelines for Enhanced Recovery after Surgery (ERAS) provide recommendations for ERAS in gastrointestinal surgery, the clinical application of standard ERAS nursing models is challenging due to the variety of diseases involved in gastrointestinal surgery and the complex factors contributing to patient stress responses. Moreover, stress responses are more severe in older adult patients. Therefore, precision medicine is required to improve the quality of nursing care and promote postoperative recovery in gastrointestinal surgery.
AIM To establish an evidence-based ERAS model based on stress response nursing care and demonstrate nursing benefits through clinical practice.
METHODS This randomized clinical trial first established an evidence-based nursing ERAS protocol in older adult patients based on literature related to perioperative nursing measures for gastrointestinal surgery stress response. Next, 392 older adult patients who underwent gastrointestinal surgery and were admitted to our hospital between December 2021 and June 2023 were categorized into two groups to receive evidence-based (study group) or conventional (control group) ERAS nursing models, respectively. Intraoperative physiological parameters during surgery and postoperative recovery indicators were compared between the groups.
RESULTS Among 64 domestic and international studies, the stress responses of older adult patients mainly included emotional anxiety, sleep disorders, gastrointestinal discomfort, physical weakness, pain, and swelling. The appropriate nursing interventions included comprehensive psychological counseling, pre- and postoperative nutritional support, temperature control, pain management, and rehabilitation training. Compared with the control group, the study group showed lower heart rate, mean arterial pressure, blood glucose level, and adrenaline level; shorter duration of drainage tube placement, time to first flatus, time to first ambulation, and postoperative hospital stay; lower anxiety scores on postoperative day 3; and lower incidences of postoperative infection, obstruction, poor wound healing, and gastrointestinal reactions were lower in the study group (all P < 0.05).
CONCLUSION The evidence-based nursing measures targeting stress responses based on the conventional ERAS nursing model resulted in stable intraoperative physiological parameters during surgery, promoted postoperative recovery, and reduced the incidence of complications.
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Affiliation(s)
- Chen-Dong Yuan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bao-Zhu Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ning-Yan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qing-Qing Wan
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Zhen-Zhen Hu
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Tankel J, Shay S, Wimpfheimer A, Neumann M, Berko R, Reissman P, Ben Haim M, Dagan A. The effect of longer epidural duration after open pancreaticoduodenectomy on pain and mobilisation: A retrospective single-centre analysis. J Perioper Pract 2024:17504589241265826. [PMID: 39104356 DOI: 10.1177/17504589241265826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. METHODS A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. RESULTS Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. CONCLUSIONS Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.
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Affiliation(s)
- James Tankel
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Shahaf Shay
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ariel Wimpfheimer
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Michael Neumann
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Robert Berko
- Department of Anesthesia, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Menahem Ben Haim
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Amir Dagan
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
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Peltoniemi P, Lehto I, Pere P, Mustonen H, Lehtimäki T, Seppänen H. Goal-directed fluid management associates with fewer postoperative fluid collections in pancreatoduodenectomy patients. Pancreatology 2023; 23:456-464. [PMID: 37258370 DOI: 10.1016/j.pan.2023.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The association between perioperative fluid management and complications in pancreatoduodenectomy patients remains controversial. We explored the association between fluid management and radiological signs of complications. METHODS We examined pancreatoduodenectomy patients operated between July 2014 and December 2015 (n = 125) and between January 2017 and June 2018 (n = 124). The first cohort received intraoperative fluid management according to a goal-directed strategy and the second cohort was treated conventionally. We analyzed fluid administration, edema visible in computed tomography (CT) scans seven days postoperatively, and radiological signs of complications occurring up to 30 days. We performed multivariable logistic regression analyses to identify risk factors for fluid collections. RESULTS No statistically significant difference in postoperative edema via CT scans emerged between the fluid management groups. However, the intraperitoneal space expanded in patients with severe Clavien-Dindo complications compared with patients experiencing mild or no complications (19.1% (IQR 10.4-40.5) vs 2.5% (IQR -7.9-16.6), p = 0.004). Fluid collections were less frequent in the goal-directed group than in the conventional fluid management group (16.8% vs 34.7%, p = 0.001). Risk factors for fluid collections included main pancreatic duct size ≤3 mm, less intraoperative fluid volume accompanying conventional fluid management, a lower postoperative urine output, and postoperative congestive heart failure. The goal-directed group received more intraoperative fluids than the conventional fluid management group and postoperative urine output was higher in the goal-directed group on postoperative days 1-3. CONCLUSIONS Optimization of intraoperative fluid management through target-controlled strategies and early diuresis were associated with a lower frequency of fluid collections in postoperative CT.
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Affiliation(s)
- Piia Peltoniemi
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inkeri Lehto
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Pertti Pere
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
| | | | - Hanna Seppänen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
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Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
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Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
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Zorrilla-Vaca A, Ripolles-Melchor J, Abad-Motos A, Mingu IR, Moreno-Jurado N, Martínez-Durán F, Pérez-Martínez I, Abad-Gurumeta A, FuenMayor-Varela ML, Mena GE, Grant MC. Association between enrollment in an enhanced recovery program for colorectal cancer surgery and long-term recurrence and survival. J Surg Oncol 2022; 125:1269-1276. [PMID: 35234283 DOI: 10.1002/jso.26836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) programs have been shown to minimize the surgical inflammatory response in colorectal cancer. Our objective was to determine the association between an ERAS program for colorectal cancer surgery and oncologic recurrence and survival. METHODS A before-after intervention study was designed, including patients who underwent colorectal cancer surgery between November 2010 and March 2016. Cox hazard regression analysis was performed per cumulative year of follow-up to evaluate the association between ERAS program exposure and overall survival. Subgroup analysis was performed by cancer stage (low [I/II] vs. advanced [III/IV]). RESULTS In total, 646 patients were included, of which 339 were pre-ERAS and 307 were ERAS. Our overall median compliance rate with ERAS interventions was 90% (interquartile range: 85%-95%). Overall survival rates were higher in the ERAS group within the first 2 years after surgery (89.2% vs. 83.2%; p = 0.04). Multivariable analysis revealed that the ERAS enrollment was associated with a significantly lower risk in 5-year oncologic recurrence (adjusted hazard ratio [aHR]: 0.55; 95% confidence interval [CI]: 0.33-0.94; p = 0.03) and higher 3-year survival (aHR: 0.55; 95% CI: 0.33-0.93; p = 0.03) among patients with advanced cancer stage compared to pre-ERAS counterparts. CONCLUSIONS Patients with advanced colorectal cancer were less likely to suffer oncologic recurrence when managed during the ERAS period.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Anesthesiology and Reanimation, Universidad del Valle, Cali, Colombia
| | | | - Ane Abad-Motos
- Department of Anesthesiology, Infanta Leonor Hospital, Madrid, Spain
| | | | | | | | | | | | | | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital School of Medicine, Baltimore, Maryland, USA
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Pawlik TM. Editorial: Enhanced Recovery after Surgery Pathways: Improving the Perioperative Experience and Outcomes of Cancer Surgery Patients. Ann Surg Oncol 2021; 28:6929-6931. [PMID: 34191179 DOI: 10.1245/s10434-021-10393-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, Columbus, USA.
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