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Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review. World J Emerg Surg 2025; 20:20. [PMID: 40065381 PMCID: PMC11892323 DOI: 10.1186/s13017-025-00597-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 03/04/2025] [Indexed: 03/14/2025] Open
Abstract
INTRODUCTION Emergency laparotomy (EmLap) is a complex clinical arena, delivering time-sensitive, definitive care to a high-risk patient cohort, with significant rates of post-operative morbidity and mortality. Embedding perioperative care pathways within this complex setting has the potential to improve post-operative outcomes, however, requires an in-depth understanding of their design, delivery and outcome assessment. Delivering and implementing complex interventions such as perioperative pathways require transparent reporting with detailed and indepth description of all components during the assessment and evaluation phase. The aim of this systematic review was to identify the current design and reporting of perioperative pathways in the EmLap setting. METHODS The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and December 2023. All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways in adult patients (> 18 years old) undergoing major emergency abdominal surgery were included. A narrative description of all perioperative pathways included was reported to identify design and description of the pathway including the delivery and timing of component interventions. All pathways were evaluated against the Template for Intervention Description and Replication (TIDieR) checklist. RESULTS Eleven RCTs and 19 non-randomised studies were identified, with most studies considered to be at moderate risk of bias. Twenty-six unique pathways were identified and described, delivering a total of 400 component interventions across 44,055 patients. Component interventions were classified into 24 domains across the perioperative pathway. Twenty studies (66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Two hundred and fifty individual outcomes were reported across pathways, with the most commonly reported outcomes related to morbidity, mortality and length of stay. CONCLUSION Current perioperative pathways in EmLap setting are underpinned by variable component interventions, with a lack of in-depth intervention reporting and evaluation. Future studies should incorporate the TIDieR checklist when reporting on perioperative pathways in the EmLap setting. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Deena P Harji
- Manchester University NHS Foundation Trust, Manchester, UK.
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Ben Griffiths
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research centre, Bristol, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Abdulkhaleq Mamalchi S, Matar M, Bass GA. Peri-operative strategy in resuscitation of unstable injured surgical patients: a primer. Postgrad Med J 2025; 101:93-99. [PMID: 39400544 DOI: 10.1093/postmj/qgae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 09/09/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND Trauma remains a leading cause of death, both for individuals under 40 in North America, and globally, where it contributes to ~10% of deaths annually. Thoughtful, timely, balanced resuscitation, especially in the peri-operative period for unstable injured surgical patients, is vital for optimizing outcomes. The advanced trauma life support protocol plays a pivotal role in early evaluation and management, emphasizing hemorrhage control and resuscitation strategies. OBJECTIVE This narrative review provides a structured, evidence-based framework aimed at enhancing the educational experience of surgical trainees. It outlines key principles in peri-operative trauma resuscitation, emphasizing timely intervention, goal-directed fluid therapy, and damage control surgery (DCS) to improve patient outcomes. METHODS A comprehensive Scale for Quality Assessment of Narrative Review Articles -guideline compliant literature search was conducted using PubMed and Google Scholar for English-language articles published between January 2000 and February 2024. The search included relevant medical subject headings terms. Additional studies were identified from reference lists. Extracted data were reviewed and organized using thematic analysis, focusing on historical perspectives, evidence-based practices, and the concept of DCS. RESULTS Key findings from the 55 relevant studies selected underscore the importance of balanced fluid and blood product administration, the use of permissive hypotension in hemorrhagic shock, and the application of DCS principles. This review highlights educational strategies that foster a deeper understanding of trauma resuscitation practices, offering practical insights through case studies and technological innovations. CONCLUSION This review serves as an educational resource for surgical trainees, equipping them with a robust understanding of evidence-based trauma resuscitation. By integrating historical context, modern practices, and emerging technologies, the review aims to enhance both the theoretical knowledge and practical skills necessary for managing unstable trauma patients. Emphasis is placed on interdisciplinary teamwork, continuous education, and personalized resuscitation strategies to improve clinical outcomes.
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Affiliation(s)
| | - Maher Matar
- Division of General Surgery Trauma Services, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada
| | - Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Medical Office Building Suite 120 (Trauma), Penn Presbyterian Medical Center, 54 N 39th Street, Philadelphia, PA, 19104, United States
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Bhamidipaty M, Suen M, Lam V, Rickard M. Surgical Heuristics with ‘Opting Out’ from an Enhanced Recovery Pathway in Octogenarian Colorectal Cancer Patients: A Retrospective Cohort Study. Indian J Surg 2024. [DOI: 10.1007/s12262-024-04194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/02/2024] [Indexed: 01/03/2025] Open
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Tian Z, Qiang G, Xiao F, Feng H, Zhang Z, Wen H, Liang C. A small-sized tube versus traditional closed thoracic drainage in uniportal thoracoscopic surgery. J Minim Access Surg 2024; 20:380-386. [PMID: 37706413 PMCID: PMC11601960 DOI: 10.4103/jmas.jmas_39_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/01/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION To assess the feasibility and safety of placing a small-sized tube as drainage in patients after uniportal thoracoscopic lung resection. PATIENTS AND METHODS Patients who received uniportal video-assisted thoracoscopic surgery (U-VATS) lung resection were identified in our database. Patients placed small-sized tube drainage were compared with those placed conventional chest tube in terms of characteristics, operation modality, post-operative pulmonary complications, post-operative pain, chest tube duration and post-operative hospital stay. Propensity score matching was performed. RESULTS Of the 217 enrolled patients, 173 were assigned to the conventional tube group and 44 were assigned to the small-sized tube group. Rates of post-operative pulmonary complications were relatively low and similar between the two groups. After propensity score matching, operation duration was shorter (1 h vs. 1.21 h, P = 0.01) was shorter, and the maximum value of the Visual Analogue Scale (VAS) score after operation (1 vs. 1.5, P = 0.02) and the overall average value of VAS score after operation (0.33 vs. 0.88, P = 0.006) was lower in small-sized tube group. No significant difference was observed in chest tube duration (2 vs. 2, P = 0.34) and post-operative hospital stay (3 vs. 3, P = 0.34). CONCLUSIONS Compared to conventional chest tubes, small-sized tubes for post-operative drainage after U-VATS lung resection may be a safe and promising approach for reducing post-operative pain.
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Affiliation(s)
- Zhoujunyi Tian
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Guangliang Qiang
- Department of Thoracic Surgery, Peking University Third Hospital, Beijing, China
| | - Fei Xiao
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Hongxiang Feng
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhenrong Zhang
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Huanshun Wen
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Chaoyang Liang
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
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Buhl MSA, Jaensch C, Madsen AH. Enhanced recovery after surgery and intestinal obstruction: A scoping review. World J Surg 2024; 48:2120-2131. [PMID: 39134899 DOI: 10.1002/wjs.12310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/21/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Acute intestinal obstruction is a blockage of the intestine which causes a range of clinical symptoms such as acute and severe abdominal pain, nausea, and obstipation. Intestinal obstruction is a medical emergency and can be life-threatening when left untreated. In cases where treatment involves emergency abdominal surgery, a multimodal perioperative care pathway (enhanced recovery after surgery ERAS) has shown to accelerate patient recovery after surgery, reduce hospital length of stay, and improve overall outcomes. The objective of this scoping review was to identify and synthesize the existing evidence regarding the implementation of ERAS components with a focus on postoperative components in patients undergoing surgery for acute intestinal obstruction. METHODS This scoping review followed the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews framework. PubMed-Medline and Embase database were searched. RESULTS The search identified 1860 studies of which 16 were included in the final analysis. All the studies were quantitative. Eleven studies used 10 or more ERAS interventions (range 10-28). The most common interventions were multimodal systemic analgesia, and the least common were the management of blood glucose and screening tools. CONCLUSION This scoping review found that 56% (n = 9/16) of the identified studies used 10 or more ERAS interventions out of a possible 35. This review highlighted the need for studies on the ERAS emergency laparotomy guidelines.
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Affiliation(s)
- Marie Sin Ae Buhl
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Gødstrup Hospital, Herning, Denmark
| | - Claudia Jaensch
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Gødstrup Hospital, Herning, Denmark
- Surgical Research Unit, NIDO Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Anders Husted Madsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Gødstrup Hospital, Herning, Denmark
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Mihăilescu AA, Onisâi M, Alexandru A, Teodorescu M, Aliuș C, Blendea CD, Neagu ȘI, Șerban D, Grădinaru S. A Comparative Analysis between Enhanced Recovery after Surgery and Traditional Care in the Management of Obstructive Colorectal Cancer. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1319. [PMID: 39202600 PMCID: PMC11356555 DOI: 10.3390/medicina60081319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/27/2024] [Accepted: 08/07/2024] [Indexed: 09/03/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) represents evidence-based transformation in perioperative care, which has been demonstrated to reduce both recovery times and postoperative complication rates. The aim of the present study was to evaluate the clinical significance of the ERAS program in comparison with conventional postoperative care. This longitudinal cohort observational study enrolled 120 consecutive patients diagnosed with intestinal obstruction caused by colorectal cancers, with 40 patients in the ERAS group and 80 patients receiving conventional postoperative care forming the non-ERAS group. Our study compares the effectiveness of ERAS protocols to non-ERAS methods, focusing on the time to first flatus, defecation, the resumption of normal diet, and early mobilization. The main endpoints are morbidity and hospitalization length. The results showed that despite a longer admission-to-surgery interval in the ERAS group, median hospitalization was significantly shorter compared to the non-ERAS group (p = 0.0002). The ERAS group showed a tendency towards a lower incidence of overall postoperative complications, indicating that implementing the ERAS protocol does not increase the risk of postoperative complications, ensuring the safety of enhanced recovery strategies for patients. Also, ERAS patients had notably fewer stomas than those in the non-ERAS group, indicating the potential effectiveness of reducing stoma necessity. This study shows that ERAS surpasses conventional care for colonic or rectal surgery patients, reducing hospital stays and costs while enhancing recovery. This highlights the comprehensive advantages of adopting ERAS in surgical settings.
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Affiliation(s)
- Alexandra-Ana Mihăilescu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- Department of Anesthesiology and Intensive Care Unit, Foisor Hospital Bucharest, 030167 Bucharest, Romania
| | - Minodora Onisâi
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- Hematology Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Adrian Alexandru
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- Department of Plastic and Reconstructive Surgery, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Matei Teodorescu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- Neurological Recovery Clinic, Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Cătălin Aliuș
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- 4th Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Corneliu-Dan Blendea
- Faculty of Medicine, Titu Maiorescu University, 040441 Bucharest, Romania; (C.-D.B.); (S.G.)
- Department of Recovery, Physical Medicine and Balneology, Ilfov County Emergency Clinical Hospital, 022104 Bucharest, Romania
| | - Ștefan-Ilie Neagu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
| | - Dragoș Șerban
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.-A.M.); (M.T.); (C.A.); (Ș.-I.N.); (D.Ș.)
- 4th Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Sebastian Grădinaru
- Faculty of Medicine, Titu Maiorescu University, 040441 Bucharest, Romania; (C.-D.B.); (S.G.)
- Department of General Surgery, Ilfov County Emergency Clinical Hospital, 022104 Bucharest, Romania
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McKechnie T, Tessier L, Archer V, Park L, Cohen D, Levac B, Parpia S, Bhandari M, Dionne J, Eskicioglu C. Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024; 50:679-704. [PMID: 37985500 DOI: 10.1007/s00068-023-02387-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/21/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care. METHODS MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE. RESULTS After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50). CONCLUSION There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Léa Tessier
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Victoria Archer
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lily Park
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Brendan Levac
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Joanna Dionne
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada.
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Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis. Br J Surg 2024; 111:znae057. [PMID: 38513265 PMCID: PMC10957158 DOI: 10.1093/bjs/znae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. METHODS The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. RESULTS Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). DISCUSSION Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.
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Affiliation(s)
- Deena P Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research Centre, Bristol, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Í Soylu L, Kokotovic D, Gögenur I, Ekeloef S, Burcharth J. Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study. Eur J Trauma Emerg Surg 2024; 50:295-304. [PMID: 37646801 PMCID: PMC10923996 DOI: 10.1007/s00068-023-02352-3] [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: 05/04/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.
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Affiliation(s)
- Lív Í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Uchino H, Nguyen-Powanda P, Tokuno J, Kouyoumdjian A, Fiore JF, Grushka J. Enhanced recovery protocols in trauma and emergency abdominal surgery: a scoping review. Eur J Trauma Emerg Surg 2023; 49:2401-2412. [PMID: 37505285 DOI: 10.1007/s00068-023-02337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. METHODS Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. RESULTS After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. CONCLUSIONS Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy.
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Affiliation(s)
- Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada.
| | - Philip Nguyen-Powanda
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
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Aggarwal A, Irrinki S, Kurdia KC, Khare S, Naik N, Tandup C, Savlania A, Dahiya D, Kaman L, Sakaray Y. Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial. World J Surg 2023; 47:2990-2999. [PMID: 37740758 DOI: 10.1007/s00268-023-07176-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery. METHODS A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis. RESULTS A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal. CONCLUSION ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.
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Affiliation(s)
- Ankit Aggarwal
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Santosh Irrinki
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kailash C Kurdia
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Siddhant Khare
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Naveen Naik
- Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Cherring Tandup
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Divya Dahiya
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Yashwant Sakaray
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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12
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Ceresoli M, Braga M, Zanini N, Abu-Zidan FM, Parini D, Langer T, Sartelli M, Damaskos D, Biffl WL, Amico F, Ansaloni L, Balogh ZJ, Bonavina L, Civil I, Cicuttin E, Chirica M, Cui Y, De Simone B, Di Carlo I, Fette A, Foti G, Fogliata M, Fraga GP, Fugazzola P, Galante JM, Beka SG, Hecker A, Jeekel J, Kirkpatrick AW, Koike K, Leppäniemi A, Marzi I, Moore EE, Picetti E, Pikoulis E, Pisano M, Podda M, Sakakushev BE, Shelat VG, Tan E, Tebala GD, Velmahos G, Weber DG, Agnoletti V, Kluger Y, Baiocchi G, Catena F, Coccolini F. Enhanced perioperative care in emergency general surgery: the WSES position paper. World J Emerg Surg 2023; 18:47. [PMID: 37803362 PMCID: PMC10559594 DOI: 10.1186/s13017-023-00519-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023] Open
Abstract
Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.
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Affiliation(s)
- Marco Ceresoli
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy.
| | - Marco Braga
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy
| | - Nicola Zanini
- General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Dario Parini
- General Surgery Department - Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Thomas Langer
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Francesco Amico
- John Hunter Hospital Trauma Service and School of Medicine and Public Health, The University of Newcastle, Newcastle, AU, Australia
| | - Luca Ansaloni
- General Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Ian Civil
- University of Auckland, Auckland, New Zealand
| | | | - Mircea Chirica
- Department of Digestive Surgery, CHU Grenoble Alpes, Grenoble, France
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Belinda De Simone
- Unit of Emergency and Trauma Surgery, Villeneuve St Georges Academic Hospital, Villeneuve St Georges, France
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Giuseppe Foti
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- Department of Critical Care and Anesthesia, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Michele Fogliata
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences (FCM), University of Campinas (Unicamp), Campinas, Brazil
| | | | | | | | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Gießen, Germany
| | | | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppäniemi
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Andrei Litvin, CEO AI Medica Hospital Center, Kaliningrad, Russia
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, Goethe University, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Ernest E Moore
- Director of Surgery Research, Ernest E. Moore Shock Trauma Center, Distinguished Professor of Surgery, University of Colorado, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Emmanouil Pikoulis
- Third Department of Surgery, Attikon University Hospital, Athene, Greece
| | - Michele Pisano
- General Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Edward Tan
- Former Chair Department of Emergency Medicine, HEMS Physician, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Giovanni D Tebala
- Digestive and Emergency Surgery Department, Azienda Ospedaliera S.Maria, Terni, Italy
| | - George Velmahos
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Head of Service and Director of Trauma, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Vanni Agnoletti
- Anesthesia and Critical Care Department, Bufalini Hospital, Cesena, Italy
| | - Yoram Kluger
- Department of General Surgery, The Rambam Academic Hospital, Haifa, Israel
| | - Gianluca Baiocchi
- General Surgery, University of Brescia, ASST Cremona, Cremona, Italy
| | - Fausto Catena
- General Surgery Department, Bufalini Hospital, Cesena, Italy
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13
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Tandup C, Chauhan A, Chauhan R, Thakur V, Sahu S, Kaman L, Khare S, Sakaray Y, Nenavath KN, Kurdia KC. Impact of Tailored-Enhanced Recovery After Surgery Versus Conventional Care in Patients of Gastro-Duodenal Perforation: A Pilot Randomized Control Trial. Cureus 2023; 15:e45349. [PMID: 37849602 PMCID: PMC10578038 DOI: 10.7759/cureus.45349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham's patch closure for gastro-duodenal perforation. METHODS A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes. RESULTS Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups. CONCLUSION Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.
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Affiliation(s)
- Cherring Tandup
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Abhinav Chauhan
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Rajeev Chauhan
- Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Vipul Thakur
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Swapnesh Sahu
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Lileswar Kaman
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Siddhant Khare
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Yashwant Sakaray
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Krishna N Nenavath
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Kailash C Kurdia
- General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
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14
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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15
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Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E, Bensard D, Sakakushev B, Galante J, Fraga GP, Koike K, Di Carlo I, Tebala GD, Leppaniemi A, Tan E, Damaskos D, De'Angelis N, Hecker A, Pisano M, Maier RV, De Simone B, Amico F, Ceresoli M, Pikoulis M, Weber DG, Biffl W, Beka SG, Abu-Zidan FM, Valentino M, Coccolini F, Kluger Y, Sartelli M, Agnoletti V, Chirica M, Bravi F, Sall I, Catena F. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg 2023; 18:38. [PMID: 37355698 DOI: 10.1186/s13017-023-00506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 06/26/2023] Open
Abstract
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.
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Affiliation(s)
- Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Giovanni D Tebala
- Oxford University Hospitals NHSFT John Radcliffe Hospital, Headley Way, HeadingtonOxford, OX3 9DU, UK
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola De'Angelis
- Hôpital Henri Mondor, Université Paris Est, Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Créteil, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ron V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walt Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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16
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Pathrikar SG, Jadhav GS, Adhikari GR. The Application of Enhanced Recovery After Surgery Protocols in Patients With Perforated Duodenal Ulcer. Cureus 2023; 15:e35760. [PMID: 37025741 PMCID: PMC10072176 DOI: 10.7759/cureus.35760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 03/07/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are nowadays considered the standard of care for various elective surgical procedures. However, its utilization remains low in tier-two and tier-three cities of India, and there exists a significant variation in the practice. In the present study, we have investigated the safety and feasibility of these protocols or pathways in emergency surgery for perforated duodenal ulcer disease. Methods A total of 41 patients with perforated duodenal ulcers were randomly divided into two groups. All the patients across the study were treated surgically with the open Graham patch repair technique. Patients in group A were managed with ERAS protocols, while patients in group B were managed with conventional peri-operative practices. A comparison was established between the two groups in terms of the duration of hospital stay and other postoperative parameters. Results The study was conducted on 41 patients who presented during the study period. Group A patients (n=19) were managed with standard protocols, and group B patients (n=22) were managed with conventional standard protocols. As compared to the standard care group, patients in the ERAS group showed quicker postoperative recovery and lesser complications. The need for nasogastric (NG) tube reinsertion, postoperative pain, postoperative ileus, and surgical site infections (SSI) were all significantly lower in the patients of the ERAS group. A significant reduction in the length of hospital stay (LOHS) was found in the ERAS group when compared to the standard care group (relative risk {RR}=61.2; p=0.000). Conclusions The application of ERAS protocols with certain modifications in the management of perforated duodenal ulcers yields significant outcomes in terms of reduced duration of hospital stay and fewer postoperative complications in a selected subgroup of patients. However, the application of ERAS pathways in an emergency setup needs to be further evaluated to develop standardized protocols for a surgical emergency group of patients.
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Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis. J Surg Res 2023; 283:469-478. [PMID: 36436282 DOI: 10.1016/j.jss.2022.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/05/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery. METHODS A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay. RESULTS Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles. CONCLUSIONS Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.
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Ylimartimo AT, Nurkkala J, Koskela M, Lahtinen S, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study. World J Surg 2023; 47:119-129. [PMID: 36245004 PMCID: PMC9726776 DOI: 10.1007/s00268-022-06783-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL. METHODS This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications. RESULTS A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications. CONCLUSIONS This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.
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Affiliation(s)
- Aura T. Ylimartimo
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Juho Nurkkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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Levy L, Smiley A, Latifi R. Adult and Elderly Risk Factors of Mortality in 23,614 Emergently Admitted Patients with Rectal or Rectosigmoid Junction Malignancy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159203. [PMID: 35954556 PMCID: PMC9368534 DOI: 10.3390/ijerph19159203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 02/05/2023]
Abstract
Background: Colorectal cancer, among which are malignant neoplasms of the rectum and rectosigmoid junction, is the fourth most common cancer cause of death globally. The goal of this study was to evaluate independent predictors of in-hospital mortality in adult and elderly patients undergoing emergency admission for malignant neoplasm of the rectum and rectosigmoid junction. Methods: Demographic and clinical data were obtained from the National Inpatient Sample (NIS), 2005−2014, to evaluate adult (age 18−64 years) and elderly (65+ years) patients with malignant neoplasm of the rectum and rectosigmoid junction who underwent emergency surgery. A multivariable logistic regression model with backward elimination process was used to identify the association of predictors and in-hospital mortality. Results: A total of 10,918 non-elderly adult and 12,696 elderly patients were included in this study. Their mean (standard deviation (SD)) age was 53 (8.5) and 77.5 (8) years, respectively. The odds ratios (95% confidence interval, P-value) of some of the pertinent risk factors for mortality for operated adults were 1.04 for time to operation (95%CI: 1.02−1.07, p < 0.001), 2.83 for respiratory diseases (95%CI: 2.02−3.98), and 1.93 for cardiac disease (95%CI: 1.39−2.70), among others. Hospital length of stay was a significant risk factor as well for elderly patients—OR: 1.02 (95%CI: 1.01−1.03, p = 0.002). Conclusions: In adult patients who underwent an operation, time to operation, respiratory diseases, and cardiac disease were some of the main risk factors of mortality. In patients who did not undergo a surgical procedure, malignant neoplasm of the rectosigmoid junction, respiratory disease, and fluid and electrolyte disorders were risk factors of mortality. In this patient group, hospital length of stay was only significant for elderly patients.
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Affiliation(s)
- Lior Levy
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA;
| | - Abbas Smiley
- Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA;
| | - Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ 85721, USA
- Correspondence:
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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21
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K M, Sahni T. Enhanced Recovery After Emergency Surgery. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03200-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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22
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Thacker J, Morin N. Optimizing Outcomes with Enhanced Recovery. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:121-139. [DOI: 10.1007/978-3-030-66049-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial. J Gastrointest Surg 2022; 26:39-49. [PMID: 34755312 DOI: 10.1007/s11605-021-05184-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency. AIMS To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis. METHODS This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups. RESULTS A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group. CONCLUSION Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge. TRIAL REGISTRATION Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).
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24
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Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00500-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.
Recent Findings
Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.
Summary
This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.
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Purushothaman V, Priyadarshini P, Bagaria D, Joshi M, Choudhary N, Kumar A, Kumar S, Gupta A, Mishra B, Mathur P, Sagar S. Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial. Trauma Surg Acute Care Open 2021; 6:e000698. [PMID: 34527811 PMCID: PMC8404432 DOI: 10.1136/tsaco-2021-000698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma. Methods In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate. Results Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups. Conclusion ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications. Level of evidence Level 1, randomized controlled trial, care management. Trial registration number Clinical Trials Registry of India (CTRI/2019/06/019533).
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Affiliation(s)
- Vijayan Purushothaman
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Pratyusha Priyadarshini
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Joshi
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Narendra Choudhary
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Purva Mathur
- Division of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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Cozza V, Barberis L, Altieri G, Donatelli M, Sganga G, La Greca A. Prediction of postoperative nausea and vomiting by point-of-care gastric ultrasound: can we improve complications and length of stay in emergency surgery? A cohort study. BMC Anesthesiol 2021; 21:211. [PMID: 34465303 PMCID: PMC8407058 DOI: 10.1186/s12871-021-01428-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative nausea and vomiting and postoperative ileus are common after major digestive surgery and represent one of the significant problems in Acute Care Surgery. The delivery model of emergency surgery needs to be improved in order to foster a patient-centered care. The multimodal approach suggested by Enhanced Recovery After Surgery (ERAS®) Guidelines is gaining widespread acceptance but is difficult to apply to emergency surgery. Ultrasound examination of the gastric antrum allows a reliable assessment of gastric contents and volume and might help contribute to improve perioperative care in the emergency setting. Methods Gastric ultrasound examinations were performed preoperatively and postoperatively on forty-one patients undergoing emergency abdominal surgery. Gastric cross-sectional area (CSA) was measured, in order to estimate the gastric volume. The data obtained were used to evaluate a possible relationship between delayed gastric emptying and postoperative adverse event. Results Gastric antrum detection rate varied from 31.8% in open up to 78.9% in laparoscopic surgeries (p = 0.003). Six patients experienced adverse outcomes, had an antiemetic therapy administered and/or a nasogastric tube inserted. Mean CSA was significantly higher in this group (12.95 cm2 vs 6.12 cm2; p = 0.040). Conclusions Sensitivity of gastric ultrasound varies depending on surgical technique. A dilated gastric antrum is significantly related to postoperative adverse outcomes and a careful ultrasound follow-up might help tailor postoperative nutrition and antiemetic therapy. In patients who experienced adverse events, antral CSA showed an average increase of more than 50% over a period of 72 h after surgery. A relative measure could be used to predict the risk of postoperative ileus. Overall, gastric ultrasound seems to be a promising diagnostic tool and a useful way to integrate ERAS® protocol in emergency abdominal surgery.
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Affiliation(s)
- Valerio Cozza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Gaia Altieri
- Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Antonio La Greca
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Roma, Italy
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Sharma J, Kumar N, Huda F, Payal YS. Enhanced Recovery After Surgery Protocol in Emergency Laparotomy: A Randomized Control Study. Surg J (N Y) 2021; 7:e92-e99. [PMID: 34104721 PMCID: PMC8175119 DOI: 10.1055/s-0041-1725156] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/30/2020] [Indexed: 01/25/2023] Open
Abstract
Introduction
There is established evidence on the role of enhanced recovery after surgery (ERAS) protocols in elective surgeries but its effectiveness in emergency surgeries has been nominally studied. We aimed at studying the feasibility and effectiveness of ERAS protocols in patients undergoing emergency abdominal surgery for intestinal perforation and small bowel obstruction and compare their surgical outcomes with conventional care.
Materials and methods
This prospective randomized study was performed for a period of 16 months. A total of 100 patients presenting either with intestinal perforation or acute small bowel obstruction were recruited; 50 each in the ERAS and the conventional care groups. The primary outcomes studied were the postoperative length of stay and 30-day morbidity and mortality.
Results
It was seen that the median (interquartile range) of the duration of hospital stay in the ERAS group was 4 (1) days while it was 7 (3) days in the conventional care group, which was statistically significant (W = 323.000, p ≤ 0.001). Similarly, postoperative morbidities like a chest infection and surgical site infections) were significant in the conventional care group.
Conclusion
The ERAS protocols are safe and effective in emergency surgeries and result in a better postoperative outcome.
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Affiliation(s)
- Jyoti Sharma
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Navin Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Farhanul Huda
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Yashwant Singh Payal
- Department of Anesthesiology, All India Institute of Medical, Sciences, Rishikesh, Uttarakhand, India
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Modified enhanced recovery after surgery protocol in patients with acute cholecystitis: efficacy, safety and feasibility. Multicenter randomized control study. Updates Surg 2021; 73:1407-1417. [PMID: 33751409 DOI: 10.1007/s13304-021-01031-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
Laparoscopic cholecystectomy (LC) is a common surgical procedure in acute cholecystitis (AC). Patients often suffer from considerable postoperative pain and indigestion, which prolongs in-hospital stay. The enhanced recovery after surgery (ERAS) program has proven its efficacy in elective surgery and could hypothetically improve outcomes of emergency LC. Currently, there is no ERAS program for LC in patients with AC. A modified ERAS (mERAS) protocol was studied in a prospective, randomized non-blinded clinical trial (NCT03754751). The mERAS group consisted of 88 patients the control group of 101 patients. The modified protocol included a patient information brochure; minimizing drain use; local anesthesia; low-pressure pneumoperitoneum; PONV prophylaxis, early mobilization and oral diet. The primary outcome was postoperative length of stay (pLOS). The postoperative length of stay in the mERAS group was shorter (24 (21-45.5) h) than in the control (45 (41-68) h) (p < 0.0001). One re-admission in the mERAS group was reported (p = 0.466). There difference in complications was insignificant (mERAS 6.8% vs 5% p = 0.757). Post-operative pain intensity was significantly lower in the mERAS group immediately after awaking (3.7 ± 1.8 vs 5.4 ± 1.3 p < 0.0001), 2 h (3.3 ± 1.7 vs 4.9 ± 1.6 p = 0.0006), 6 h (2.9 ± 1.5 vs 4.2 ± 1.2 p < 0.0001), 12 h (2.7 ± 0.9 vs 4.1 ± 1.2 p = 0.0001) and 24 h after surgery (2.1 ± 1.2 vs 3 ± 1.2 p < 0.0001). The incidence of shoulder and neck pain was lower in mERAS group (13.6% vs 34.7% p = 0.0009). Peristalsis recovery was similar in both groups. The proposed protocol improved postoperative recovery and reduced hospital stay in patients with AC without increasing the rate of complications or re-admissions.
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Xu D, Yin Y, Hou L, Zhou H. A special acute care surgery model for dealing with dilemmas involved in emergency department in China. Sci Rep 2021; 11:1723. [PMID: 33462376 PMCID: PMC7813847 DOI: 10.1038/s41598-021-81347-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/30/2020] [Indexed: 12/26/2022] Open
Abstract
There was a fast growth in the number and the formation of emergency department (ED) visits in China during the twenty-first century. As a result, engaging special medical model will be essential to decompressing the ED visits. To do this, it will be important to understand which specific aspects to focus interventions on for the greatest impact. To characterize the emergency surgery patients who were seen and discharged from ED. Retrospective cohort study of hospitalized emergency surgery patients currently under the care from specialists presenting to an urban, university affiliated hospital between 01 January 2018 and 1 January 2019. This study will highlight some of the controversies and challenges and key lessons learned. During the study period there were 231,229 ED visits; 4100 of these patients were admitted for Acute care surgery (ACS) service. Multivariate analysis identified age ≧ 65 (p = 0.023; odds ratio, OR = 2.66), ACS model (p = 0.000, OR = 0.18), ICU stay (p = 0.000, OR = 118.73) as factors associated with in-hospital mortality. There was a increase in length of stay between young and elderly postoperative patients when stratifying patients by age (11.67 ± 9.48 vs 13.95 ± 9.11 p < 0.05). ED overcrowding is not just an ED problem. ED overcrowding is a systems problem requiring a systematic facility-wide multidisciplinary response. Continuous and high-quality surveillance data across China are needed to estimate the acute care surgery model which used to deal with ED overcrowding.
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Affiliation(s)
- Dequan Xu
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Yue Yin
- Department of Thyroid Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
| | - Limin Hou
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China.
| | - Haoxin Zhou
- Department of Emergency Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, People's Republic of China
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Sampaio MAF, Sampaio SLP, Leal PDC, Moura ECR, Alvares LGGS, DE-Oliveira CMB, Torres OJM, Martins MDG. ACERTO PROJECT: IMPACT ON ASSISTANCE OF A PUBLIC EMERGENCY HOSPITAL. ACTA ACUST UNITED AC 2021; 33:e1544. [PMID: 33470374 PMCID: PMC7812687 DOI: 10.1590/0102-672020200003e1544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Background: In Brazil, the goal-based approach was named Project ACERTO and has obtained
good results when applied in elective surgeries with shorter hospitalization
time, earlier return to activities without increased morbidity and
mortality. Aim: To analyze the impact of ACERTO on emergency surgery care. Methods: An intervention study was performed at a trauma hospital. Were compared 452
patients undergoing emergency surgery and followed up by the general surgery
service from October to December 2018 (pre-ACERTO, n=243) and from March to
June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused
postoperative venous hydration, duration of use of catheters, probes and
drains, postoperative analgesia, prevention of postoperative vomiting, early
mobilization and physiotherapy were evaluated. Results: After the ACERTO implantation there was earlier reintroduction of the diet,
the earlier optimal caloric intake, earlier venous hydration withdrawal,
higher postoperative analgesia prescription, postoperative vomiting
prophylaxis and higher physiotherapy and mobilization prescription were
achieved early in all (p<0.01); in the multivariate analysis there was no
change in the complication rates observed before and after ACERTO (10.7% vs.
7.7% (p=0.268) and there was a decrease in the length of hospitalization
after ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusion: The implementation of the ACERTO project decreased the length of hospital
stay, improved medical care provided without increasing the rates of
complications evaluated.
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Affiliation(s)
| | | | - Plinio da Cunha Leal
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
| | - Ed Carlos Rey Moura
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
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Anania G, Campagnaro A, Marchetti F, Resta G, Cirocchi R. Perforated Gastroduodenal Ulcer. EMERGENCY LAPAROSCOPIC SURGERY IN THE ELDERLY AND FRAIL PATIENT 2021:129-139. [DOI: 10.1007/978-3-030-79990-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Rossi IR, Ross SW, May AK, Reinke CE. Readmission After Emergency General Surgery: NSQIP Review of Risk, Cause and Ideal Follow-Up. J Surg Res 2020; 260:359-368. [PMID: 33387679 DOI: 10.1016/j.jss.2020.11.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Emergency General Surgery (EGS) population is particularly at high risk for readmission. Currently, no system exists to predict which EGS patients are most at risk. We hypothesized that a subset of EGS patients could be identified with increased 30-day unplanned readmission. We also hypothesized that a majority of readmissions occur sooner than the conventional 2-week follow-up period. METHODS National Surgical Quality Improvement Program (NSQIP) nonelective general surgery patients were analyzed. Multivariable logistic regression identified factors with increased odds of unplanned readmission. AAST EGS Diagnosis Categories were used to categorize postop ICD-9 codes, and the top 10 CPT codes in each group were analyzed. Readmission rate, the reason for unplanned readmission, and time to readmission were analyzed. RESULTS A total of 383,726 patients were identified with a readmission rate of 8.1% within 30 d of their primary procedure. The top 50 CPT codes accounted for 84% of EGS readmissions. Increased readmission risk was demonstrated for underweight patients (OR = 1.15, P < 0.05). High-risk hospital characteristics were LOS >2 d, any inpatient pulmonary complications, and discharge to any facility or rehab (all P < 0.05). Surgical site infections cause nearly 25% of readmissions. Intestinal procedures are most frequently readmitted (22% of EGS readmissions), with colorectal procedures having the higher odds of readmission. Most readmissions occur <10 d after discharge. CONCLUSIONS A high-risk subpopulation exists within EGS, and most readmissions occur sooner than a typical 2-week follow-up. Early interventions for high-risk EGS subpopulations may allow for early intervention and reduction of unnecessary healthcare utilization.
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Affiliation(s)
- Isolina R Rossi
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina.
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Chndan MN, Khakholia M, Bhuyan K. Enhanced Recovery after Surgery (ERAS) Versus Standard Care in Patients Undergoing Emergency Surgery for Perforated Peptic Ulcer. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02195-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Delestre M, Berge P, Aubé C, Hamy A, Hamel JF, Paisant A, Venara A. Nasogastric tube after small bowel obstruction surgery could be avoided: a retrospective cohort study. Eur J Trauma Emerg Surg 2020; 48:39-45. [PMID: 33095278 DOI: 10.1007/s00068-020-01529-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/09/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The safety and feasibility of early removal of nasogastric tube (NGT) after small bowel obstruction (SBO) surgery have not yet been assessed. Such a practice could allow to implement enhanced recovery after surgery (ERAS) protocols after acute SBO surgery. The aims of this study were to assess the safety of early NGT removal by comparing the short-term outcomes of patients with postoperative NGTs and those with no postoperative NGT. METHODS All patients undergoing surgery for strangulation or adhesive SBO between January the 1st of 2014 and December the 31st of 2017 were retrospectively included. RESULTS Among the 123 included, NGT was removed immediately after the end of the procedure in 26 cases (21.1%) and 19 patients required NGT replacement (15.4%). In univariate analysis, early removal of NGT was significantly associated with a reduction of overall morbidity, severe morbidity and postoperative ileus occurrence. Multivariate analysis confirmed that NGT left in place was a risk factor for postoperative ileus [Odd Ratio (OR) 4.9, Confidence Interval (CI) 95% 1.3-19.2; p = 0.02], while it has no incidence on severe morbidity. CONCLUSIONS Early NGT removal after ASBO surgery seemed to be feasible, safe and efficient, at least in selected patients. This primary study represents the initial foundations for building the implementation of ERAS protocols after ASBO surgery.
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Affiliation(s)
- Maxime Delestre
- Department of Digestive and Endocrinal Surgery, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
- University of Medicine of Angers, Angers, France
| | - Pierre Berge
- University of Medicine of Angers, Angers, France
- Department of Radiology, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Christophe Aubé
- University of Medicine of Angers, Angers, France
- Department of Radiology, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
- HIFIH, UPRES EA 3859, University of Angers, Angers, France
| | - Antoine Hamy
- Department of Digestive and Endocrinal Surgery, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
- University of Medicine of Angers, Angers, France
- Department of Radiology, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-François Hamel
- Department of Biostatistics, Maison de la Recherche, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Anita Paisant
- University of Medicine of Angers, Angers, France
- Department of Radiology, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
- HIFIH, UPRES EA 3859, University of Angers, Angers, France
| | - Aurélien Venara
- Department of Digestive and Endocrinal Surgery, University Hospital of Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.
- University of Medicine of Angers, Angers, France.
- HIFIH, UPRES EA 3859, University of Angers, Angers, France.
- UMR INSERM U1235, TENS, The Enteric Nervous System in Gut and Brain Disorders Institut Des Maladies de l'Appareil Digestif, 1, rue Gaston Veil, 44035, Nantes, France.
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Fischer CP, Knapp L, Cohen ME, Ko CY, Reinke CE, Wick EC. Feasibility of Enhanced Recovery in Emergency Colorectal Operation. J Am Coll Surg 2020; 232:178-185. [PMID: 33069852 DOI: 10.1016/j.jamcollsurg.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Emergency colorectal operations account for considerable surgical morbidity, leading to increased recognition of the importance of standardized care. Enhanced recovery pathways (ERPs) have successfully provided a framework to standardize elective surgical care, with some ERP elements spreading to emergency procedures. This study aims to characterize the degree of spread and demonstrate feasibility of ERP extension to emergency colorectal operations. STUDY DESIGN Patients undergoing colorectal operations were identified from a national ERP collaborative. Adherence to ERP process measures-multimodal pain control, early Foley removal, postoperative venous thromboembolism prophylaxis, early mobilization, early feeding, and 30-day clinical outcomes-was analyzed. Multivariable logistic regression was used to evaluate association between process measure adherence and 30-day clinical outcomes. RESULTS A total of 31,511 patients underwent colorectal operations at 235 hospitals; 3,086 were emergencies and 28,425 were elective. For emergency cases, rates of early Foley removal (92.0%) and venous thromboembolism prophylaxis (75.7%) were highest. Rates of multimodal pain control (55.9%), early mobilization (37.1%), and early liquid intake (33.4%) were modest. Nonadherence was more common in patients younger than 65 years (43.4%), with independent functional status (94%), American Society of Anesthesiologists Physical Status Classification 1 to 3 (62.5%), and without physiologic derangement (39.9%). Lack of mobilization or liquid intake was independently associated with increased odds of ileus (odds ratio [OR] 1.43; 95% CI, 1.18 to 1.75 and OR 2.41; 95% CI, 1.96 to 2.95) and prolonged length of stay (OR 2.29; 95% CI, 1.85 to 2.83 and OR 2.05; 95% CI, 1.70 to 2.47). CONCLUSIONS Although the unplanned nature of emergency colorectal operations historically excluded patients from ERPs, our findings suggest ERPs have observable diffusion beyond elective surgical procedures. Deliberate implementation with adherence auditing can improve ERP uptake and outcomes in emergency colorectal operations.
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Affiliation(s)
- Chelsea P Fischer
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
| | - Leandra Knapp
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Mark E Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | | | - Elizabeth C Wick
- Department of Surgery, University of California, San Francisco, CA; Johns Hopkins Medicine, Armstrong Institute for Quality and Safety, Baltimore, MD
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Technical Evidence Review for Emergency Major Abdominal Operation Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2020; 231:743-764.e5. [PMID: 32979468 DOI: 10.1016/j.jamcollsurg.2020.08.772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
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Saurabh K, Sureshkumar S, Mohsina S, Mahalakshmy T, Kundra P, Kate V. Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial. J Gastrointest Surg 2020; 24:2077-2087. [PMID: 32632732 DOI: 10.1007/s11605-020-04684-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures. AIMS To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery. METHODOLOGY This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed. RESULTS Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001). CONCLUSION Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.
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Affiliation(s)
- Kumar Saurabh
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Sathasivam Sureshkumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Subair Mohsina
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Thulasingam Mahalakshmy
- Department of Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Pankaj Kundra
- Anesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India.
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Zhang X, Yang J, Chen X, Du L, Li K, Zhou Y. Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses. Medicine (Baltimore) 2020; 99:e20983. [PMID: 32702839 PMCID: PMC7373593 DOI: 10.1097/md.0000000000020983] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties. OBJECTIVES To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery. DESIGN An umbrella review of meta-analyses. DATE SOURCES PubMed, Embase, Web of Science and the Cochrane Library. RESULTS The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67). CONCLUSION The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.
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Affiliation(s)
- Xingxia Zhang
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xinrong Chen
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Liang Du
- Chinese Evidence-Based Medicine/Cochrane Center, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Yong Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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Enhanced Recovery After Emergency Surgery: Utopia or Reality? Cir Esp 2020; 99:258-266. [PMID: 32532473 DOI: 10.1016/j.ciresp.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/19/2020] [Accepted: 04/26/2020] [Indexed: 11/20/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.
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Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation. Sci Rep 2020; 10:7346. [PMID: 32355193 PMCID: PMC7193622 DOI: 10.1038/s41598-020-64242-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/05/2020] [Indexed: 02/04/2023] Open
Abstract
The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.
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Grass F, Pache B, Butti F, Solà J, Hahnloser D, Demartines N, Hübner M. Fluid management for critical patients undergoing urgent colectomy. J Eval Clin Pract 2020; 26:109-114. [PMID: 31206242 DOI: 10.1111/jep.13207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 12/20/2022]
Abstract
RATIONALE The present study aimed to define thresholds for perioperative fluids and weight gain after urgent colectomies. METHOD Consecutive urgent colonic resections within an enhanced recovery pathway (2011-2017) were included. Primary outcomes were postoperative complications, stratified as overall (I-V) and major (IIIb-V) according to Clavien scale. Fluid-management-related thresholds were identified through receiver operating characteristics (ROC) analysis. Outcomes were compared for patients above vs below threshold, and multivariable logistic regression was performed to identify risk factors for overall complications. RESULTS Overall, complications were observed in 133 out of 224 patients (59%), severe complications in 43 patients (19%). For overall complications, area under ROC (AUROC) was 0.71, identifying a critical cut-off of 3 L of total IV fluid administration at the day of surgery (negative predictive value [NPV]: 90%). Further, a critical cut-off for postoperative weight gain of 2.3 kg at postoperative day (POD) 2 was identified (AUROC 0.7, NPV 92%). Multivariable analysis identified fluid administration of >3 L (OR 5.33; 95% CI, 2.36-12.02) and weight gain of >2.3 kg at POD 2 (OR 2.5; 95% CI, 1.13-5.53) as independent predictors for overall complications. Median length of stay was 7 (5-10) days in patients receiving <3 L at POD 0 and 13 (9-19) days in patients receiving >3 L (P < .001). CONCLUSIONS Fluid administration of 3 L at the day of surgery and weight gain of 2.3 kg at POD 2 may represent critical thresholds for adverse outcomes after urgent colectomy. The suggested thresholds need to be confirmed through independent validation.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Fabio Butti
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Josep Solà
- Centre Suisse d'Electronique et de Microtechnique (CSEM), Neuchâtel, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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Boyd-Carson H, Gana T, Lockwood S, Murray D, Tierney GM. A review of surgical and peri-operative factors to consider in emergency laparotomy care. Anaesthesia 2020; 75 Suppl 1:e75-e82. [PMID: 31903572 DOI: 10.1111/anae.14821] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/12/2022]
Abstract
Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.
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Affiliation(s)
- H Boyd-Carson
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - T Gana
- Bradford Royal Infirmary, Yorkshire and Humber Deanery, Leeds, UK
| | | | - D Murray
- James Cook University Hospital, Middlesbrough, UK
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Hajibandeh S, Hajibandeh S, Bill V, Satyadas T. Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery. World J Surg 2020; 44:1336-1348. [DOI: 10.1007/s00268-019-05357-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lohsiriwat V. Enhanced recovery after surgery for emergency colorectal surgery: Are there any differences between intra-abdominal infection and other indications? J Visc Surg 2019; 156:489-496. [DOI: 10.1016/j.jviscsurg.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Cui Z, Zhang Y, Xu C, Ding C, Chen J, Li C, Zhao J. Comparison of the results of two chest tube managements during an enhanced recovery program after video-assisted thoracoscopic lobectomy: A randomized trial. Thorac Cancer 2019; 10:1993-1999. [PMID: 31475791 PMCID: PMC6775025 DOI: 10.1111/1759-7714.13183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study compared the results of the application of two different chest tube management systems; a drainage ball with low negative pressure and the more commonly used chest tube with water-sealed bottle, after video-assisted thoracoscopic (VATS) lobectomy. METHODS A total of 60 patients undergoing lobectomy were enrolled into this prospective open label randomized clinical trial and equally divided into two groups. The data collected in the trial included age, gender, forced expiratory volume in 1 second (FEV1), blood loss, operation time, drainage volume, drainage time, length of stay, postoperative pain score according to the Visual Analogue Scale (VAS) within 24 hours after surgery and chest tube removal. This study was registered at ClinicalTrials.gov (NCT03598296). RESULTS The characteristics of the patients were similar in both groups. Group ball patients had a lower pain score (after operation: 3.47 ± 1.80 vs. 6.20 ± 1.56, P < 0.001; after removal of chest tube: 1.47 ± 1.28 vs. 3.00 ± 1.29, P < 0.001); less analgesic used (2.83 ± 2.09 times vs. 5.00 ± 3.24 times, P = 0.003); less drainage time (upper tube: 3.89 ± 1.63 days vs. 5.10 ± 2.02 days, P = 0.048; lower tube: upper lobe 4.84 ± 1.61 days vs. 5.90 ± 1.52 days, P = 0.041; lower lobe: 3.82 ± 1.08 days vs. 5.70 ± 2.63 days, P = 0.042) and shorter length of stay (5.40 ± 1.65 days vs. 6.37 ± 1.99 days, P = 0.045). All other related parameters were similar in both groups. CONCLUSIONS For patients undergoing lobectomy, using a drainage ball with negative pressure could reduce hospitalization days and postoperative pain compared with the more commonly used chest tube with water-sealed bottle when a strict postoperative curative procedure was performed.
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Affiliation(s)
- Zihan Cui
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Yuejuan Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Chun Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Cheng Ding
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Jun Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Chang Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
| | - Jun Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Medical college of Soochow University, Suzhou, China
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Use of minimally invasive surgery in emergency general surgery procedures. Surg Endosc 2019; 34:2258-2265. [PMID: 31388806 DOI: 10.1007/s00464-019-07016-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. METHODS The 2007-2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. RESULTS During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001). CONCLUSIONS Use of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10 years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.
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Sazhin AV, Nechay TV, Titkova SM, Tyagunov AE, Anurov MV, Melnikov-Makarchuk KY, Tyagunov AA, Ermakov IV, Glagolev NS, Kurashinova LS, Ivanova EA, Nechay VS, Karpov AV, Mirzoyan AT, Ivakhov GB, Balakirev YS. [Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]. Khirurgiia (Mosk) 2019:15-23. [PMID: 30307416 DOI: 10.17116/hirurgia2018090115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To analyze outcomes of fast track rehabilitation in patients with acute appendicitis. MATERIAL AND METHODS Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent. RESULTS Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications. CONCLUSION There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - M V Anurov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K Yu Melnikov-Makarchuk
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - A A Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - N S Glagolev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - L S Kurashinova
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - E A Ivanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V S Nechay
- Medical Institute of Tula State University
| | - A V Karpov
- Moscow Clinical Hospital #4, Moscow, Russia
| | - A T Mirzoyan
- City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - G B Ivakhov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - Yu S Balakirev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
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Lee GC, Hodin RA. Applying Enhanced Recovery Pathways to Unique Patient Populations. Clin Colon Rectal Surg 2019; 32:134-137. [PMID: 30833863 DOI: 10.1055/s-0038-1676479] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Enhanced Recovery after Surgery (ERAS) pathways have become popular in colorectal surgery due to their associated decrease in length of stay (LOS), complications, and readmission rate. However, it is unclear if these pathways are safe, feasible, or effective in unique patient populations such as elderly patients, urgent/emergent surgeries, patients with specific comorbidities, inflammatory bowel disease, or pediatric patients. Enhanced recovery pathways appear safe in elderly patients, associated with decreased complications, though with slightly lower rates of adherence and increased LOS and readmission rates. Modified ERAS pathways have been applied to urgent and emergent surgeries, resulting in decreased morbidity and LOS. There have been no studies that performed subgroup analyses of ERAS pathways in patients with specific comorbidities. Studies investigating patients with inflammatory bowel disease on enhanced recovery pathways are extremely limited, but suggest that they are safe and feasible. Data on ERAS pathways in pediatric patients are still emerging. Therefore, though data are sparse, enhanced recovery pathways appear to be safe in unique patient populations, with similar efficacy in decreasing LOS and complications. There is an urgent need for more studies investigating these specific patient groups to aid perioperative decision making by colorectal surgeons.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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50
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Lohsiriwat V, Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices. World J Gastrointest Surg 2019; 11:41-52. [PMID: 30842811 PMCID: PMC6397799 DOI: 10.4240/wjgs.v11.i2.41] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Romyen Jitmungngan
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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