In the early phase of the Covid-19 pandemic, mainly data related to the burden of care required by infected patients were reported. The aim of this study was to illustrate the timeline of actions ...taken and to measure and analyze their impact on surgical patients.
This is a retrospective review of actions to limit Covid-19 spread and their impact on surgical activity in a Swiss tertiary referral center. Data on patient care, human resources and hospital logistics were collected. Impact on surgical activity was measured by comparing 6-week periods before and after the first measures were taken.
After the first Swiss Covid-19 case appeared on February 25, progressively restrictive measures were taken over a period of 23 days. Covid-19 positive inpatients increased from 5 to 131, and ICU patients from 2 to 31, between days 10 and 30, respectively, without ever overloading resources. A 43% decrease of elective visceral surgical procedures was observed after Covid-19 (295 vs 165, p<0.01), while the urgent operations (all specialties) decreased by 39% (1476 vs 897, p<0.01). Fifty-two and 38 major oncological surgeries were performed, respectively, representing a 27% decrease (p = 0.316). Outpatient consultations dropped by 59%, from 728 to 296 (p<0.01).
While allowing for maximal care of Covid-19 patients during the pandemic, the shift of resources limited the access to elective surgical care, with less impact on cancer care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Pressurised intraperitoneal aerosol chemotherapy (PIPAC) was introduced as a new treatment for patients with peritoneal metastases in November, 2011. Reports of its feasibility, tolerance, and ...efficacy have encouraged centres worldwide to adopt PIPAC as a novel drug delivery technique. In this Review, we detail the technique and rationale of PIPAC and critically assess its evidence and potential indications. A systematic search was done to identify all relevant literature on PIPAC published between Jan 1, 2011, and Jan 31, 2019. A total of 106 articles or reports on PIPAC were identified, and 45 clinical studies on 1810 PIPAC procedures in 838 patients were included for analysis. Repeated PIPAC delivery was feasible in 64% of patients with few intraoperative and postoperative surgical complications (3% for each in prospective studies). Adverse events (Common Terminology Criteria for Adverse Events greater than grade 2) occurred after 12–15% of procedures, and commonly included bowel obstruction, bleeding, and abdominal pain. Repeated PIPAC did not have a negative effect on quality of life. Using PIPAC, an objective clinical response of 62–88% was reported for patients with ovarian cancer (median survival of 11–14 months), 50–91% for gastric cancer (median survival of 8–15 months), 71–86% for colorectal cancer (median survival of 16 months), and 67–75% (median survival of 27 months) for peritoneal mesothelioma. From our findings, PIPAC has been shown to be feasible and safe. Data on objective response and quality of life were encouraging. Therefore, PIPAC can be considered as a treatment option for refractory, isolated peritoneal metastasis of various origins. However, its use in further indications needs to be validated by prospective studies.
Background
Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS ...pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.
Methods
A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.
Results
A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.
Conclusions
The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
Abstract Background Enhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection ...(UTI). The aim of this study was to identify risk factors for urinary retention (UR). Methods This retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates. Results The study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; P = 0.045) and postoperative thoracic epidural anesthesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, P = 0.024) and gained more weight (2.8 ± 2.5 kg versus 1.6 ±3 kg on day 1, P = 0.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1 ± 2.5 versus 2.2 ± 2.4, P = 0.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, P = 0.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR ( P = 0.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR ( P = 0.991). Conclusions Male gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery.
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. ...Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. ...Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.
The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.
Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVE:To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery.
BACKGROUND:EDA is mainstay of multimodal pain ...management within enhanced recovery pathways enhanced recovery after surgery (ERAS). For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious.
METHODS:A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle.
RESULTS:Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range IQR, 3–7.5 days) in EDA patients and 4 days (IQR, 3–6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications 19 (33%) vs 35 (54%); P = 0.029 but a similar hospital stay 5 days (IQR, 4–8 days) vs 7 days (IQR, 4.5–12 days); P = 0.434. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted.
CONCLUSIONS:Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.
BACKGROUND:Adequate selection of patients with peritoneal metastasis (PM) for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains critical for successful ...long-term outcomes. Factors reflecting tumor biology are currently poorly represented in the selection process. The prognostic relevance of RAS/RAF mutations in patients with PM remains unclear.
METHODS:Survival data of patients with colorectal PM operated in 6 European tertiary centers were retrospectively collected and predictive factors for survival identified by Cox regression analyses. A simple point-based risk score was developed to allow patient selection and outcome prediction.
RESULTS:Data of 524 patients with a median age of 59 years and a median peritoneal cancer index of 7 (interquartile range3–12) were collected. A complete resection was possible in 505 patients; overall morbidity and 90-day mortality were 50.9% and 2.1%, respectively. PCI hazard ratio (HR)1.08, N1 stage (HR2.15), N2 stage (HR2.57), G3 stage (HR1.80) as well as KRAS (HR1.46) and BRAF (HR3.97) mutations were found to significantly impair survival after CRS/HIPEC on multivariate analyses. Mutations of RAS/RAF impaired survival independently of targeted treatment against EGFR. Consequently, a simple point-based risk score termed BIOSCOPE (BIOlogical Score of COlorectal PEritoneal metastasis) based on PCI, N-, G-, and RAS/RAF status was developed, which showed good discrimination development area under the curve (AUC) = 0.72, validation AUC = 0.70, calibration (P = 0.401) and allowed categorization of patients into 4 groups with strongly divergent survival outcomes.
CONCLUSION:RAS/RAF mutations impair survival after CRS/HIPEC. The novel BIOSCOPE score reflects tumor biology, adequately stratifies long-term outcomes, and improves patient assessment and selection.
Background. Surgical stress during major surgery may be related to adverse clinical outcomes and early quantification of stress response would be useful to allow prompt interventions. The aim of this ...study was to evaluate the acute phase protein albumin in the context of the postoperative stress response. Methods. This prospective pilot study included 70 patients undergoing frequent abdominal procedures of different magnitude. Albumin (Alb) and C-reactive protein (CRP) levels were measured once daily starting the day before surgery until postoperative day (POD) 5. Maximal Alb decrease (Alb Δ min) was correlated with clinical parameters of surgical stress, postoperative complications, and length of stay. Results. Albumin values dropped immediately after surgery by about 10 g/L (42.2±4.5 g/L preoperatively versus 33.8±5.3 g/L at day 1, P<0.001). Alb Δ min was correlated with operation length (Pearson ρ=0.470, P<0.001), estimated blood loss (ρ=0.605, P<0.001), and maximal CRP values (ρ=0.391, P=0.002). Alb Δ min levels were significantly higher in patients having complications (10.0±5.4 versus 6.1±5.2, P=0.005) and a longer hospital stay (ρ=0.285, P<0.020). Conclusion. Early postoperative albumin drop appeared to reflect the magnitude of surgical trauma and was correlated with adverse clinical outcomes. Its promising role as early marker for stress response deserves further prospective evaluation.
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