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Jiang W, Zeng X, Zhou X, Liao O, Ju F, Zhao Z, Zhang X. Effect of magnesium sulfate perioperative infusion on postoperative catheter-related bladder discomfort in male patients undergoing laparoscopic radical resection of gastrointestinal cancer: a prospective, randomized and controlled study. BMC Anesthesiol 2023; 23:396. [PMID: 38042781 PMCID: PMC10693125 DOI: 10.1186/s12871-023-02346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Laparoscopic radical resection of gastrointestinal cancer is associated with a high incidence of postoperative catheter-related bladder discomfort (CRBD). Studies on the benefits of magnesium sulfate intravenous infusion during the perioperative period post-laparoscopic surgery are yet lacking. METHODS A total of 88 gastrointestinal cancer male patients scheduled for laparoscopic radical resection were randomly divided into two groups: normal saline (control) and magnesium. In the magnesium group, a 40 mg/kg loading dose of intravenous magnesium sulfate was administered for 10 min just after the induction of anesthesia, followed by continuous intravenous infusion of 15 mg/kg/h magnesium sulfate until the end of the surgery; the control group was administered the same dose of normal saline. Subsequently, 2 μg/kg sufentanil was continuously infused intravenously by a postoperative patient-controlled intravenous analgesia (PCIA) device. The primary outcome was the incidence of CRBD at 0 h after the surgery. The secondary outcomes included incidence of CRBD at 1, 2, and 6 h postsurgery, the severity of CRBD at 0, 1, 2, and 6 h postsurgery. Remifentanil requirement during surgery, sufentanil requirement within 24 h postsurgery, the postoperative numerical rating scale (NRS) score at 48 h after the surgery, magnesium-related side effects and rescue medication (morphine) requirement were also assessed. RESULTS The incidence of CRBD at 0, 1, 2, and 6 h postoperatively was lower in the magnesium group than the control group (0 h: P = 0.01; 1 h: P = 0.003; 2 h: P = 0.001; 6 h: P = 0.006). The incidence of moderate to severe CRBD was higher in the control group at postoperative 0 and 1 h (0 h: P = 0.002; 1 h: P = 0.028), remifentanil requirement during surgery were significantly lower in the magnesium group than the control group. Sufentanil requirements during the 24 h postoperative period were significantly lower in the magnesium group than the control group. The NRS score was reduced in the magnesium group compared to the control group in the early postoperative period. Magnesium-related side effects and rescue medication (morphine) did not differ significantly between the two groups. CONCLUSIONS Intravenous magnesium sulfate administration reduces the incidence and severity of CRBD and remifentanil requirement in male patients undergoing radical resection of gastrointestinal cancer. Also, no significant side effects were observed. TRIAL REGISTRATION Chictr.org.cn ChiCTR2100053073. The study was registered on 10/11/2021.
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Affiliation(s)
- Wencai Jiang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Xu Zeng
- Clinical Medicine Department, Chengdu Medical College, Chengdu, 610500, China
| | - Xinyu Zhou
- Clinical Medicine Department, Chengdu Medical College, Chengdu, 610500, China
| | - Ou Liao
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Feng Ju
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Zhifu Zhao
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Xianjie Zhang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China.
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Shao J, Xie J, Sun P, Zhang Y, Chen D, Chen Y, Xu M. Factors Influencing Postoperative Recovery Time of Patients With Gastric Cancer. Surg Laparosc Endosc Percutan Tech 2023; 33:370-374. [PMID: 37235717 DOI: 10.1097/sle.0000000000001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/31/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND To explore the factors associated with prolonged enhanced recovery after surgery (ERAS) time in gastric cancer patients who underwent gastrectomy. METHODS This was a retrospective of patients with gastric cancer who received ERAS at our hospital between 01/2014 and 01/2022. The outcome was prolonged ERAS time. Factors associated with prolonged ERAS time of patients undergoing gastric cancer surgery were analyzed by logistic regression. RESULTS Among 663 patients, 182 (27.6%) patients had a prolonged ERAS time. The postoperative time to the first flatus time was 2.8 ± 1.2 days. There were 41 (6.2%) patients with intestinal obstruction, 25 (3.8%) with abdominal infection, and four (0.5%) with anastomotic leakage. The multivariable analysis showed that age >80 years (OR = 1.57, 95% CI: 1.31-4.40, P = 0.048), laparoscopic surgery (OR = 0.45, 95% CI: 0.21-0.95, P = 0.035), intraoperative jejunostomy (OR = 334.60, 95% CI: 2.81-39,831.90, P = 0.017), postoperative time to the first flatus time (OR = 3.79, 95% CI: 1.23-11.68, P = 0.021), total gastrectomy (OR = 0.08, 95% CI: 0.01-0.94, P = 0.044), and patient compliance with ERAS (OR = 0.01, 95% CI: 0-0.09, P < 0.001) were independently associated with prolonged ERAS time. CONCLUSIONS Age >80 years, laparoscopic surgery, intraoperative jejunostomy, postoperative time to the first flatus time, total gastrectomy, and patient compliance with ERAS might be factors associated with prolonged ERAS time in gastric cancer patients.
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Affiliation(s)
- Jun Shao
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Jiang Xie
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Peng Sun
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Yunpeng Zhang
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Daqing Chen
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Ying Chen
- Department of Oncology, Shanghai Tongren Hospital, Shanghai China
| | - Ming Xu
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
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Gil LA, Asti L, Apfeld JC, Sebastião YV, Deans KJ, Minneci PC. Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies. J Pediatr Surg 2022; 57:755-762. [PMID: 35985848 DOI: 10.1016/j.jpedsurg.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches. METHODS The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes. RESULTS 12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5). CONCLUSIONS MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes. MINI-ABSTRACT In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Yuri V Sebastião
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Division of Global Women's Health, School of Medicine, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA.
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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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Outcomes of surgical management of post laparoscopy atypical myco-bacterial port site infections: Is early surgery a better alternative? SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2021.100054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Mallard SR, Clifford KA, Park R, Cousins K, Patton A, Woodfield JC, Thompson-Fawcett M. Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study. BMC Surg 2021; 21:132. [PMID: 33726715 PMCID: PMC7962301 DOI: 10.1186/s12893-021-01149-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. METHODS Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). RESULTS Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. CONCLUSIONS Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team's expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.
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Affiliation(s)
- Simonette R Mallard
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Kari A Clifford
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - R Park
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Kim Cousins
- Department of Preventive and Social Medicine, Dunedin Medical Campus, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ann Patton
- Dunedin Public Hospital, Dunedin, New Zealand
| | - John C Woodfield
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Mark Thompson-Fawcett
- Department of Surgical Sciences, Dunedin Medical Campus, Otago Medical School, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
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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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Mazzotta E, Villalobos-Hernandez EC, Fiorda-Diaz J, Harzman A, Christofi FL. Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols. Front Pharmacol 2020; 11:583422. [PMID: 33390950 PMCID: PMC7774512 DOI: 10.3389/fphar.2020.583422] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.
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Affiliation(s)
- Elvio Mazzotta
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Fievos L. Christofi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Factors influencing the application of transrectal natural orifice specimen extraction performed laparoscopically for colorectal cancer: A retrospective study. Asian J Surg 2020; 44:164-168. [PMID: 32513636 DOI: 10.1016/j.asjsur.2020.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/22/2020] [Accepted: 04/30/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A few factors influence the feasibility of transrectal natural orifice specimen extraction (NOSE) surgery for colorectal cancers. However, little is known about the underlying factors of NOSE surgery. METHODS Consecutive patients with rectal and sigmoid colon cancers treated laparoscopically between January 2014 and April 2017 were enrolled in this study. The transrectal NOSE performed laparoscopically was the first choice of all patients. When NOSE failed, the specimen was removed through a midline abdominal wall incision. Univariate and multivariate logistic regression analyses were performed to identify challenging factors influencing the intraoperative specimen extraction. RESULTS Overall, 412 consecutive patients were included. NOSE performed laparoscopically was successful in 278 patients (75.5%) and unsuccessful in 90 patients (24.5%). The multivariate analyses indicated that body mass index (BMI; odds ratio [OR] = 3.510, 95% confidence interval [CI]: 1.333-9.243, p = 0.011), mesenteric thickness (OR = 1.069, 95% CI: 1.032-1.107, p < 0.001), maximum tumor diameter (OR = 2.827, 95% CI: 1.094-7.302, p = 0.032), and tumor T stage (OR = 2.831, 95% CI: 1.258-6.369, p = 0.012) were the factors influencing the feasibility of NOSE surgery. CONCLUSION A successful transrectal NOSE surgery was associated with a lower BMI, thinner mesentery, lesser tumor diameter, and earlier tumor T stage.
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Garmpis N, Dimitroulis D, Garmpi A, Diamantis E, Spartalis E, Schizas D, Angelou A, Margonis GA, Farmaki P, Antoniou EA, Mantas D, Markatos K, Kontzoglou K, Damaskos C. Enhanced Recovery After Surgery: Is It Time to Change Our Strategy Regarding Laparoscopic Colectomy? In Vivo 2019; 33:669-674. [PMID: 31028183 PMCID: PMC6559898 DOI: 10.21873/invivo.11525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/08/2023]
Abstract
Enhanced recovery after surgery or 'fast-track' methods are evidence-based protocols designed to standardize post-operative medical care, improve patient outcomes, promote early recovery, and reduce healthcare expenditure. Fast-track surgery is a multifunctional concept involving pre-, peri- and post-operative measures aiming to reduce the length of hospital stay and morbidity and complication rates, following elective abdominal surgery. Through the optimization of peri-operative care and the recovery process in adherence to these fast-track protocols, improved outcomes are reached, surgical trauma and post-operative stress are reduced, with less surgical pain, reduced complications, and shorter length of hospital stay. Fast-track care requires a multidisciplinary collaboration of all healthcare professionals, as well as a high rate of protocol compliance and a good organizational structure. Despite the existing evidence of the benefits of fast-track protocols in a variety of surgical procedures and the similar outcomes of laparoscopic colonic surgery compared to open surgery, clear evidence of the benefits of fast-track care after laparoscopic colonic surgery is yet to be clearly demonstrated.
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Affiliation(s)
- Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Garmpi
- Internal Medicine Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Eleftherios Spartalis
- N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Paraskevi Farmaki
- First Department of Pediatrics, Agia Sofia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios A Antoniou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Mantas
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Kontzoglou
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Resalt-Pereira M, Muñoz JL, Miranda E, Cuquerella V, Pérez A. Goal-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery program. ACTA ACUST UNITED AC 2019; 66:259-266. [PMID: 30862401 DOI: 10.1016/j.redar.2019.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Enhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients.?. OBJECTIVE To compare 2fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative náusea and vomiting, and variability of the estimated glomerular filtration rate (eGFR). MATERIALS AND METHODS An observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate. RESULTS A total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative náusea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR.?. CONCLUSION The results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.
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Affiliation(s)
- M Resalt-Pereira
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España.
| | - J L Muñoz
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - E Miranda
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - V Cuquerella
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - A Pérez
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
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12
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Tebala GD, Gallucci A, Khan AQ. The impact of complications on a programme of enhanced recovery in colorectal surgery. BMC Surg 2018; 18:60. [PMID: 30115063 PMCID: PMC6097404 DOI: 10.1186/s12893-018-0390-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/02/2018] [Indexed: 01/22/2023] Open
Abstract
Background The advantages of Enhanced Recovery (ER) programmes are well known, in terms of improved overall experience of the patients, which associates with low morbidity and reduced length of stay. As a result, the pattern of morbidity is changing and some patients may develop complications after discharge. Aim of this work was to evaluate the impact of morbidity and related outcomes such as unplanned readmission and reoperation rate on an ER programme in colorectal surgery. Methods Prospectively collected clinical data of patients who underwent colorectal resection have been retrospectively analysed. Endpoints were: 90-day mortality and morbidity, length of hospital stay (LOS) and rate of unplanned readmissions and reoperations. Results Mortality and morbidity did not change in the analysed period, but LOS reduced significantly. Main determinant of postoperative LOS was the type of surgical approach, laparoscopy being associated with earlier discharge. LOS was longer in patients who developed complications. Morbidity and reoperation rate were significantly higher in patients discharged after day 4. Majority of complications happened in patients who were still in the hospital. However, the few patients who developed complications after discharge did not have a worse outcome if compared to those who had complications in hospital. Conclusions ER protocols must become integral part of the perioperative management of colorectal patients. ER and laparoscopy have a synergic effect to improve the postoperative recovery and reduce morbidity. Early discharge of patients does not affect the outcome of postoperative complications.
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Affiliation(s)
- Giovanni D Tebala
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK. .,East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Kennington Rd, Willesborough, Ashford, Kent, TN24 0LZ, UK.
| | | | - Abdul Q Khan
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK
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13
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Wang LH, Zhu RF, Gao C, Wang SL, Shen LZ. Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis. World J Gastroenterol 2018; 24:1562-1578. [PMID: 29662294 PMCID: PMC5897860 DOI: 10.3748/wjg.v24.i14.1562] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery (ERAS) protocols in elective gastric cancer (GC) surgery.
METHODS PubMed, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials (RCTs) comparing ERAS protocols and standard care (SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment.
RESULTS No significant difference was observed between ERAS and control groups regarding total complications (P = 0.88), mortality (P = 0.50) and reoperation (P = 0.49). The incidence of pulmonary infection was significantly reduced (P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS (P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay (P < 0.00001) and medical costs (P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus (P = 0.0004) and the first defecation (P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior short-term quality of life (QOL).
CONCLUSION Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.
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Affiliation(s)
- Liu-Hua Wang
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
- Department of General Surgery, Yizheng People’s Hospital, Yangzhou 211400, Jiangsu Province, China
| | - Ren-Fei Zhu
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Cheng Gao
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Shou-Lin Wang
- School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu Province, China
| | - Li-Zong Shen
- Division of Gastrointestinal Surgery, Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
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14
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Siotos C, Stergios K, Naska A, Frountzas M, Pergialiotis V, Perrea DN, Nikiteas N. The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies. Surgeon 2018; 16:183-192. [PMID: 29337046 DOI: 10.1016/j.surge.2017.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fast track surgery has been implemented in colorectal procedures during the last decade and is accompanied by significant improvement in patient outcomes during the early postoperative period. However, to date, its adoption in upper gastrointestinal surgery remains a matter of debate. In this context, we aimed to summarize the existing evidence in the international literature. MATERIALS AND METHODS We searched Medline, Scopus, ClinicalTrials.gov and Cochrane Central Register databases for published randomized controlled trials. The meta-analysis was performed with the RevMan 5.3.5 software. MAIN FINDINGS Thirty studies were finally included in the present meta-analysis. The post-operative morbidity was not influenced by the implementation of fast track surgery (FTS) (OR 0.84, 95% CI 0.64-1.09). However, in cases treated with laparoscopic surgery fast track surgery seemed to reduce morbidity by 50% (p = .006). The overall mortality of patients was low in the majority of included studies and was not influenced by fast track surgery (OR 1.12, 95% CI 0.50-2.52). The duration of postoperative hospitalization was significantly reduced with the adoption of FTS (MD -2.24, 95% CI -2.63 to -1.85 days). Concurrently, the overall cost was significantly reduced in cases treated with FTS (MD -982.30, 95% CI -1367.68 to -596.91 U.S dollars). CONCLUSION According to the findings of our meta-analysis suggest that FTS seems to be safe in patients undergoing upper gastrointestinal surgery and reduce both the days of postoperative hospitalization and the overall cost. This observation should be taken into account in future recommendations to enhance the implementation of FTS protocols in current clinical practice.
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Affiliation(s)
- Charalampos Siotos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stergios
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of General Surgery, Watford General Hospital - West Hertfordshire Hospitals NHS Trust, UK.
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, WHO Collaborating Center for Food and Nutrition Policies, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Nikiteas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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15
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Ommundsen N, Wyller TB, Nesbakken A, Bakka AO, Jordhøy MS, Skovlund E, Rostoft S. Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial. Colorectal Dis 2018. [PMID: 28649755 DOI: 10.1111/codi.13785] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC. METHOD Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival. RESULTS One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05). CONCLUSION A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.
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Affiliation(s)
- N Ommundsen
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - T B Wyller
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - A Nesbakken
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.,K.G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway
| | - A O Bakka
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - M S Jordhøy
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,The Cancer Unit, Innlandet Hospital Trust, Hamar, Norway
| | - E Skovlund
- Department of Public Health and Nursing, NTNU, Norway
| | - S Rostoft
- Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
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16
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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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Lau CSM, Chamberlain RS. Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World J Surg 2016; 41:899-913. [DOI: 10.1007/s00268-016-3807-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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[Risk awareness and training for prevention of complications in minimally invasive surgery]. Chirurg 2016; 86:1121-7. [PMID: 26464347 DOI: 10.1007/s00104-015-0097-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIC) requires surgeons to have a different set of skills and capabilities from that of open surgery. The indirect camera view, lack of a three-dimensional view, restricted haptic feedback with lack of tissue feeling and difficult instrument coordination with fulcrum and pivoting effects result in an additional learning curve compared to open surgery. The prolonged learning curve leads to a higher risk of complications and special awareness of these risks is therefore mandatory. Training of special laparoscopic skills outside the operating room is needed to optimize patient outcome and to minimize the ocurrence of complications related to the learning curve. RESULTS AND DISCUSSION Training modalities for laparoscopic surgery include simple box trainers, computer simulation with virtual reality, the use of artificial and cadaver organs, as well as live animal models and cadaver training. These training modalities have been proven in studies to have a beneficial effect on the learning curve for acquisition of laparoscopic skills and for improving operative performance as well as avoidance of complications. Laparoscopic training is currently gaining a more and more important role for official education and accreditation purposes. In some countries the participation in laparoscopic training courses has become mandatory prior to participation in laparoscopic operations. Future research will include the optimization of multimodal training curricula, the development of individualized training approaches that allow both trainee and patient-specific preparation, as well as the use of novel devices to facilitate the collection and transfer of expertise between the generations and schools of surgeons.
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Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies. Surg Res Pract 2016; 2016:7543684. [PMID: 27642630 PMCID: PMC5013204 DOI: 10.1155/2016/7543684] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/29/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06-2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program.
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20
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Thorn CC, White I, Burch J, Malietzis G, Kennedy R, Jenkins JT. Active and passive compliance in an enhanced recovery programme. Int J Colorectal Dis 2016; 31:1329-39. [PMID: 27112591 DOI: 10.1007/s00384-016-2588-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome. MATERIALS AND METHODS A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of 'active compliance' is introduced. An ERAS element is classified as 'active' if the participation of the patient is required to achieve its compliance. This contrasts with 'passive' compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance. RESULTS Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance. CONCLUSION The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.
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Affiliation(s)
| | - Ian White
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Jennie Burch
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | | | - Robin Kennedy
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK
| | - John T Jenkins
- St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
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Sasmal PK, Mishra TS, Rath S, Meher S, Mohapatra D. Port site infection in laparoscopic surgery: A review of its management. World J Clin Cases 2015; 3:864-871. [PMID: 26488021 PMCID: PMC4607803 DOI: 10.12998/wjcc.v3.i10.864] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/08/2015] [Accepted: 07/27/2015] [Indexed: 02/05/2023] Open
Abstract
Laparoscopic surgery (LS), also termed minimal access surgery, has brought a paradigm shift in the approach to modern surgical care. Early postoperative recovery, less pain, improved aesthesis and early return to work have led to its popularity both amongst surgeons and patients. Its application has progressed from cholecystectomies and appendectomies to various other fields including gastrointestinal surgery, urology, gynecology and oncosurgery. However, LS has its own package of complications. Port site infection (PSI), although infrequent, is one of the bothersome complications which undermine the benefits of minimal invasive surgery. Not only does it add to the morbidity of the patient but also spoils the reputation of the surgeon. Despite the advances in the field of antimicrobial agents, sterilization techniques, surgical techniques, operating room ventilation, PSIs still prevail. The emergence of rapid growing atypical mycobacteria with multidrug resistance, which are the causative organism in most of the cases, has further compounded the problem. PSIs are preventable if appropriate measures are taken preoperatively, intraoperatively and postoperatively. PSIs can often be treated non-surgically, with early identification and appropriate management. Macrolides, quinolones and aminoglycosides antibiotics do show promising activity against the atypical mycobacteria. This review article highlights the clinical burden, presentations and management of PSIs in LS as shared by various authors in the literature. We have given emphasis to atypical mycobacteria, which are emerging as a common etiological agent for PSIs in LS. Although the existing literature lacks consensus regarding PSI management, the complication can be best avoided by strictly abiding by the commandments of sterilization techniques of the laparoscopic instruments with appropriate sterilizing agent.
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McLemore EC, Paige JT, Bergman S, Hori Y, Schwarz E, Farrell TM. Ongoing evolution of practice gaps in gastrointestinal and endoscopic surgery: 2014 report from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee. Surg Endosc 2015; 29:3017-29. [DOI: 10.1007/s00464-015-4525-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/19/2015] [Indexed: 11/27/2022]
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