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Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of "fast-track" protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patien...
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Purpose:
Data on urethral catheter related injuries is sparse. To highlight the dangers inherent with traumatic urethral catheterisation (UC) we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries.
Materials and methods:
This prospective study was performed during a 6-month period in two tertia...
Abstract: Objective: Pancreaticoduodenectomy is a technically challenging surgery requiring longer period of recovery post operatively. This study aims to examine the implementation of an enhanced recovery after surgery (ERAS) protocol following pancreaticoduodenectomy. Methods: All patient undergone pancreaticoduodenectomy were managed following E...
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A retrospective study included 271 patients who underwent laparotomic SCP for symptomatic pelvic organ prolapse from November 2008 to June 2013 at our institution. By the review of medical records, perioperative and post...
Background
Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified. Methods
We evaluated...
Citations
... As ERAS is new to the field of LT, similar issues are expected to occur. In the first years of the implementation of ERAS in colorectal surgery, many issues arose concerning patient and physician capability of correctly implementing and accepting what proved to be a validated protocol for better patient recovery [21,22] including the complexity of these multimodal pathways [23], the need for teamwork along with the difficulty of eradicating old surgical stereotypes of traditional care. Agrafiotis et al [24], along with the first author of the present review, have explored in 2013 the efficacy of a "soft" non-strict fast-track protocol in a cohort of 92 patients undergoing colorectal surgery. ...
Background:
Enhanced recovery after surgery (ERAS) started a revolution that changed age-old surgical stereotypical practices regarding the overall management of the surgical patient. In the last decade, ERAS has gained significant acceptance in the community of general surgery, in addition to several other surgical specialties, as the evidence of its advantages continues to grow. One of the last remaining fields, given its significant complexity and intricate nature, is liver transplantation (LT).
Aim:
To investigate the existing efforts at implementing ERAS in LT.
Methods:
We conducted a systematic review of the existing studies that evaluate ERAS in orthotopic LT, with a multimodal approach and focusing on measurable clinical primary endpoints, namely length of hospital stay.
Results:
All studies demonstrated a considerable decrease in length of hospital stay, with no readmission or negative impact of the ERAS protocol applied to the postoperative course.
Conclusions:
ERAS is a well-validated multimodal approach for almost all types of surgical procedures, and its future in selected LT patients seems promising, as the preliminary results advocate for the safety and efficacy of ERAS in the field of LT.
... The common outcome derived from the results of many literature studies is that in addition to all contributions of ERAS protocol, it does not change the postoperative mortality rates and duration of rehospitalization [26][27][28][29][30][31]. However, since it requires a robust team work its implementation in every institute or unit is not easy [32]. Indeed, in a study by Jimenes et al., the authors indicated that adherence to ERAS protocol was a very slow process, and it was not practised at an anticipated level [2]. ...
Objectives:
In the present study, we aimed to compare the postoperative compliance and complications between ERAS and conventional postoperative care in patients undergoing abdominal hysterectomies.
Material and methods:
This is the prospective, randomized, controlled trial, which involved 62 patients, who underwent abdominal hysterectomy between December 2016 to February 2017. A total of 30 patients formed the ERAS group. A total of 32 patients who received conventional perioperative care and matched for age, body mass index (BMI) and American Society of Anesthesiologists score were assigned as a control group. Groups were compared in terms of patient characteristics [age, body mass index, ASA Score, parity, diagnosis, type of surgery, and perioperative intravenous fluids], postoperative compliance (postoperative intravenous fluids, time to first flatus, first defecation, ambulation, eating solid food, and postoperative hospital stay), and postoperative complications.
Results:
Peri- and post-operative administrated intravenous fluids were significantly lower in the ERAS group (p < 0.001 for both). Time to first flatus (p = 0.001), time to first defecation (p < 0.001), and time to eating solid food (p < 0.001) were all significantly shorter in the ERAS group. Post-operative early mobilization on the first postoperative day was achieved in eight (26.7%) patients in the ERAS group. There were no significant differences in complications. One (3.3%) patient in the ERAS Group and 11 (34.4%) patients in the Conventional Group required hospital readmission after discharge (p = 0.002).
Conclusion:
The ERAS protocol seems to be a simple tool for reducing the incidence of postoperative complications and shortening hospitalization.
... We therefore focused on the effects of overall ERAS protocol compliance with outcomes. Two studies [67,68] excluded patients who developed complications in order to reduce the confounding effect of morbidity on ERAS protocol compliance. ...
... The most frequently identified predictors of a prolonged LOS, or delayed discharge, was reduced compliance with ERAS protocols [32,34,63,67,68,70] both globally and with specific components (delayed mobilisation [57,59,63,64,70] and delayed resumption of oral intake [59,60,63,67,70]; Table 2). Increased ASA grade [34,58,67] and older patient age frequently were predicted for a longer LOS. ...
... The most frequently identified predictors of a prolonged LOS, or delayed discharge, was reduced compliance with ERAS protocols [32,34,63,67,68,70] both globally and with specific components (delayed mobilisation [57,59,63,64,70] and delayed resumption of oral intake [59,60,63,67,70]; Table 2). Increased ASA grade [34,58,67] and older patient age frequently were predicted for a longer LOS. ...
Objective
To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery. BackgroundERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood. MethodsA systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures. ResultsThirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission. Conclusion
Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection.
... These results are similar to those of several other clinical studies [13,14], and they further verify that the FTS program reduces inflammation, protects immune homeostasis during the perioperative period, and promotes enhanced recovery after surgery. However, there was no difference in the duration of postoperative hospitalization between the two groups, which was inconsistent with the results of other foreign studies [15,16]. This inconsistency may be attributed to the traditional values of our patients, because some patients in China are willing to stay in the hospital until the standard discharge time, even if they have recovered [2]. ...
Objective
The objective of this study is to explore the effects of the fast-track surgery (FTS) program on inflammation and immunity in patients undergoing colorectal surgery. Methods
From August 2014 to March 2015, a prospective and randomized controlled trial of 230 patients who underwent colorectal surgery was performed. The patients were randomly assigned to an FTS group (116 patients) or a traditional group (114 patients). Inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups. ResultsThe inflammatory mediators (CRP, IL-6, TNF-α) were lower in the FTS group than in the traditional group (P < 0.05) on postoperative day (POD) 1, POD 4, and POD 6, and the immunological indicators (IgG, IgA, C3, C4) of the FTS group were superior to those of the traditional group (P < 0.05) on POD 4 and POD 6. The time to first aerofluxus, defecation, oral intake, and ambulation after surgery was shorter in the FTS group than in the traditional group (P < 0.05); however, the duration of postoperative hospitalization did not differ significantly between the two groups (P > 0.05). The total complications were significantly lower in the FTS group than in the traditional group (P < 0.05). Conclusion
The FTS program can decrease inflammation, maintain immune homeostasis, and improve rehabilitation effects in colorectal surgery patients.
... Some authors say it is not necessary because MBP does not lower the rate of leakage from the anastomosis [27]. Similarly, use of postoperative drainage does not lower the leakage rate and may lead to prolonged hospitalization [28]. In our department, a drain after a non-complicated resection is left for 24 h only in the case of LAR and we acknowledge this is a divergence from ERAS guidelines. ...
Most of the studies concerning enhanced recovery after surgery (ERAS) protocols in colorectal surgery include heterogeneous groups of patients undergoing open or laparoscopic surgery, both due to colonic and rectal cancer, thus creating a potential bias. The data investigating the differences between patients operated for either colonic or rectal cancer are sparse. The aim of the study was to compare short-term outcomes of laparoscopic surgery for colonic and rectal cancer with ERAS protocol. The analysis included consecutive prospectively registered patients operated for a colorectal cancer between January 2012 and September 2015. Patients were divided into two groups (colon vs. rectum). The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilization and time to first flatus). Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. Patients in Group 1
Enhanced Recovery after Surgery (ERAS) protocols are multimodal perioperative care pathways designed to accelerate recovery by minimizing the physiologic stress of a surgical procedure. Benefits of ERAS implementation in colorectal surgery include reduced length of stay and decreased complications without an increase in readmissions. Though there is evidence associating individual ERAS protocol elements (e.g., preoperative carbohydrate loading, judicious perioperative fluid administration, and early initiation of postoperative nutrition) with improved outcomes, ensuring high compliance with all elements of an ERAS protocol will maximize benefits to the patient. After ERAS implementation, data collection on protocol process measures can help providers target education and interventions to improve protocol compliance and patient outcomes.
Background
Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.
Objective
Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.
Methods
Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.
Results
Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1–4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.
Conclusion
We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.
Background
We aimed to evaluate postoperative recovery and short-term outcomes of patients undergoing partial hepatectomy managed with a nonstrict and individual enhanced recovery after surgery (ERAS) program. MethodsA retrospective analysis of 168 partial hepatectomy patients in our institution was included. The discharged day and the respective impact of element application throughout the duration were analyzed. ResultsWhen all the required elements of ERAS were fully implemented, the median discharge day was 6. The more deviation occurred, the more delayed the patient discharged (P < 0.01). Preoperative ASA score, basic conditions of patients and ages were revealed closely associated with discharge day (P < 0.001). Without or an early removal of tubes and early oral feeding reduced hospital stay statistically (P < 0.01). Early discharge of patients (<3 days) did not show an increased complication incidence or readmission (P > 0.05). Conclusion
Nonstrict and individual use of ERAS in partial hepatectomy reduced postoperative length of stay without increasing complication rate. Our study proposes a modulation of ERAS according to the needs and acceptance of patients. In a word, better optionally required rather than mandatorily meet.
Résumé
Introduction
Si l’intérêt de la réhabilitation améliorée après chirurgie colorectale a pu être prouvé sur la morbidité et la durée d’hospitalisation postopératoire, son impact sur la durée de reprise du transit est peu documenté. Les objectifs étaient d’évaluer l’impact de la réhabilitation améliorée sur la reprise du transit, et d’évaluer l’importance de la définition de l’iléus et son incidence rapportée dans la littérature.
Matériel et méthodes
Il s’agit d’une étude observationnelle prospective monocentrique portant sur tous les patients consécutifs opérés d’une résection-anastomose colorectale sur 17 mois. La reprise d’un transit global était définie par la récupération d’un transit de matière associé à la tolérance à l’alimentation solide.
Résultats
Cent trente et un patients étaient inclus avec une adhésion médiane de 14 (13 ; 16) items suivis sur les 19 items traceurs. Le délai médian de reprise du transit gazeux était de 2 jours alors que le délai de reprise d’un transit de matière était de 3 jours. Le délai de reprise d’un transit gazeux ainsi que d’un transit global diminuait quand l’observance au protocole augmentait (respectivement p < 0,001 ; r² = 0,11 et p = 0,04 ; r² = 0,06). L’incidence de l’iléus était de 1,5 à 61,8 % en fonction de la définition de l’iléus (cut-off de 1 à 7 jours). Une observance au protocole ≥ 85 % protégeait de l’apparition d’un iléus ≥ 4 jours (OR = 0,35 ; IC 95 % = 0,15–0,83).
Conclusion
La mise en place et l’observance d’un protocole de réhabilitation améliorée après chirurgie permettait une diminution du délai de reprise du transit mais une définition consensuelle de l’iléus est nécessaire.
Introduction:
While enhanced recovery after surgery (ERAS) has been proven to improve results in colorectal operations with regard to morbidity and duration of hospital stay, its impact on recovery of bowel motility is poorly documented. The aims of this study were to assess the impact of ERAS on bowel motility recovery, and to assess the consequences of the definition of postoperative ileus on its reported incidence in the literature.
Material and methods:
This is a single-center prospective observational study of consecutive patients who underwent colorectal resection with anastomosis over a period of 17 months. Global resumption of intestinal transit (GROT) was defined as passage of stool combined with alimentary tolerance of solid food.
Results:
One hundred and thirty-one patients were included. A median of 14 items (range: 13-16) was complied out of 19 observable items in the protocol. Median time to passage of flatus (MTPF) was 2 days and the GROT was 3 days. The time interval to MTPF as well as to GROT decreased as adherence to the ERAS protocol increased (respectively P<0.001, r(2)=0.11 and P=0.04, r(2)=0.06). The incidence of postoperative "ileus" varied from 1.5% to 61.8% depending on the interval chosen to define ileus (cut-off from 1 to 7 days). Adherence to≥85% of the items in the ERAS protocol protected patients from "prolonged ileus", i.e., lasting≥4 days (OR=0.35; 95% CI=0.15 to 0.83).
Conclusion:
The implementation of and compliance with an ERAS protocol allowed a reduction in the time to GROT. There is a need for a consensual definition of postoperative ileus.
