Regional anesthetic nerve blocks are widely used in the treatment of pain after outpatient surgery to reduce opioid consumption. Erector spinae plane (ESP) block is a recently described technique ...with promising results in different scenarios.
To compare ESP block efficacy with the commonly used transversus abdominis plane (TAP) block in patients undergoing robot-assisted inguinal hernia repair.
This was a randomized, blinded, active controlled, superiority trial with 2 parallel groups. The study was approved by the local ethics committee. Registration took place on; www.
gov with the identifier NCT04750512.
Adults undergoing robotic inguinal hernia repair were recruited between January 2021 and April 2022 in a single referral center of southern Switzerland.
To ensure blinding, the study employed a "double dummy" design, where all patients underwent both TAP and ESP blocks, but only one block was therapeutically active. The therapeutic block contained ropivacaine 0.2%, while the other infiltration contained placebo. The therapeutic intervention varied between groups, with one group receiving the TAP block as the active treatment and the other group receiving the ESP block as the active treatment. Computer generated 1:1 randomization determined allocation, which took place immediately prior to the intervention. As a result, blinding included patients, anesthesia, and surgery providers, outcome assessors and statistical analysts. The main outcome measure was the highest reported pain score on a Visual Analog Scale (VAS) during the 6 hours following the end of general anesthesia. Secondary outcomes included pain scores at set intervals, analgesic consumption, and complications.
A total of 50 patients (25 per arm) were enrolled and included in the analysis. The study found no significant difference in the mean maximal VAS scores between the 2 groups (TAP block 22.2, ESP block 20, difference 2.2, 95% CI is -12.1 to 16.5). Secondary endpoints, including VAS pain scores at different time points, use of rescue analgesics, time to first walk, duration of stay, and frequency of adverse events, did not show any significant differences between the 2 groups. However, post-hoc analysis suggested a more stable effect over time for the ESP block compared to the TAP block.
The main limitation is a higher variance in VAS scores than expected in the power calculations.
ESP block was not superior to TAP block in the treatment of post-operative pain among patients undergoing robotic inguinal hernia repair.
Background
Learning curves describe the rate of performance improvements according to the surgeon’s caseload, followed by a plateau where limited additional improvements are observed. The aim of this ...study was to evaluate the learning curve for robotic-assisted transabdominal preperitoneal repair (rTAPP) for inguinal hernias in surgeons already experienced in laparoscopic TAPP.
Methods
The study was approved by local ethic committee. Male patients undergoing rTAPP for inguinal hernia from October 2017 to December 2019 at the Bellinzona Regional Hospital were selected from a prospective database. Demographic and clinical data, including operative time, conversion to laparoscopic or open surgery, intra- and postoperative complications were collected and analyzed.
Results
Over the study period, 170 rTAPP were performed by three surgeons in 132 patients, and mean age was 60.1 ± 13.7 years. The cumulative summation (CUSUM) test showed a significant operative time reduction after the 43
rd
operation, once the 90% proficiency on the logarithmic tendency line was achieved. The corrected operative time resulted 71.1 ± 22.0 vs. 60.8 ± 13.5 min during and after the learning curve (
p
= 0.011). Only one intraoperative complication occurred during the learning curve and required an orchiectomy. Postoperatively, three complications (one seroma, one hematoma, and one mesh infection) required invasive interventions during the learning curve, while no cases were recorded after it (
p
= 0.312).
Conclusion
Our study shows that the rTAPP, performed by experienced laparoscopists, has a learning curve which requires 43 inguinal hernia repairs to achieve 90% proficiency and to significantly reduce the operative time.
The aim of this study was to assess if laparoscopic-assisted transversus abdominis plane (TAP) block (L-TAPB) is as efficient as ultrasound-guided TAP block (U-TAPB) in postoperative pain control.
In ...all, 112 patients scheduled for elective laparoscopic colon resection from February 2018 to December 2021 at two Swiss hospitals were included and randomized in a 1:1 ratio before surgery with either L-TAPB or U-TAPB. The primary end-point was the non-inferiority of the L-TAPB compared to U-TAPB with regard to the total opioid consumption within the first 24 h after surgery. Data regarding patients' characteristics, opioid consumption, pain on the visual analogue scale, operative and anaesthesia induction time, complications and length of stay were collected and analysed.
Fifty-five patients were allocated to the L-TAPB and fifty-seven to the U-TAPB. No significant difference was found in the overall dose of opioids within 24 h, and the non-inferiority of the L-TAPB was confirmed. There were almost twice as many patients in the L-TAPB group requesting opioid reserves compared to the U-TAPB group (54.5% vs. 29.8%, P = 0.008). The anaesthesia induction time was significantly longer in the U-TAPB group (17 ± 11 min vs. 23 ± 12 min, P = 0.014). For all other variables (pain on the visual analogue scale, opioid consumption, need of epidural analgesia, operating time, postoperative complications and hospital stay) no statistically significant difference between the L-TAPB and the U-TAPB groups was noted.
Our results showed the non-inferiority of the laparoscopic delivery compared to ultrasound-guided administration of the TAP block, with the advantage of not affecting anaesthesia times.
2017-02017 CE 3294, ClinicalTrials.gov identifier NCT04575233.
Purpose
In this double-blind randomized trial, we aimed to compare the postoperative pain, complications, and length of hospital stay in patients undergoing open hemorrhoidectomy under spinal ...anesthesia with or without the pudendal nerve block.
Methods
Patients undergoing Milligan-Morgan hemorrhoidectomy under spinal anesthesia were randomized to undergo a pudendal nerve block or no intervention. Postoperative pain on the visual analogue scale (VAS) at 6, 12, 24, and 48 h; opioid administration; and length of hospital stay were recorded and analyzed.
Results
Over the study period, 49 patients were included and 23 randomized in the treatment arm. No differences in terms of age, gender, and preoperative risk factors were noted between groups. The pain on the VAS at 6, 12, 24, and 48 h was 2.8 vs. 4.6 (
p
= 0.046), 3.4 vs. 4.7 (
p
= 0.697), 1.4 vs. 3.1 (
p
= 0.016), and 1.0 vs. 2.1 (
p
= 0.288) in the treatment and control groups respectively. No differences in opioids use or complications were noted. Length of hospital stay was 1.2 vs. 1.8 days respectively (
p
= 0.046). No complications directly associated to the pudendal nerve block were observed. Multivariate analysis revealed that the pudendal nerve block was an independent factor reducing the postoperative pain.
Conclusions
The ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy under spinal anesthesia showed a statistically significant reduction in postoperative pain and length of hospital stay. The proposed technique appeared to be safe and feasible and may be recommendable in patients undergoing open hemorrhoidectomy.
Trial registration
ClinicalTrials.gov
Identifier: NCT04251884
In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting.
A systematic literature search was ...conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used).
One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result.
Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.
BACKGROUND: Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood ...loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown.
METHODS: We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs.
RESULTS: A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland’s German-speaking regions (Odds Ratio OR 3.39, 95% confidence interval CI 1.23–9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48–10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines.
CONCLUSIONS: Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.
Background
Anastomotic leakage after colorectal surgery is a complication that requires additional treatments strongly affecting the economic outcomes. We evaluated the use of resources and the ...economic burden associated with anastomotic leaks following colorectal surgery.
Methods
Between January 2015 and December 2016, we retrospectively evaluated patients who underwent colorectal surgery with primary anastomosis. We compared the medical resource utilization and the DRG-based reimbursement of cases with uncomplicated surgery and cases complicated by anastomotic leakage.
Results
Of the 95 patients included in the study, 87 (92%) presented an uneventful postoperative course and 8 patients (8%) developed an anastomotic leakage requiring surgery. The statistical analysis showed no significant differences in terms of demographics, risks factor, and operative results, except the length of hospital stay (9.7 vs. 29.1 days,
p
< 0.01). The cost for 87 uncomplicated cases was 1,535,297 EUR (average cost of 17,647 EUR), whereas the cost of the 8 patients with anastomotic leakage was 575,822 EUR (average cost of 71,978 EUR) (
p
< 0.01). For each patient, the hospital had 542 EUR profit in the uncomplicated group and a 12,181 EUR loss in the anastomotic leakage group (
p
< 0.01). The multiple R-squared line regression analysis showed that factors independently related to costs were age (
p
= 0.05) and length of hospital stay (
p
= 0.01).
Conclusions
In terms of economic impact, the occurrence of an anastomotic leakage has a large negative influence on medical resource utilization, so that, despite the complication-related increase of DRG-reimbursement, every complicated case represents a financial burden for the hospital.
Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to ...calculate CMH and to increase cost-effectiveness.
For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH.
Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random “first come–first serve” basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001).
Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.
Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the ...incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs.
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (“regional anesthesia” OR “nerve block”) AND (“complications” OR “nerve lesion” OR “nerve damage” OR “nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed.
Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000.
Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.
Post-polypectomy coagulation syndrome (PECS) is a well-known adverse event after endoscopic polypectomy for colorectal lesions. To date, there are no standardized guidelines for the antimicrobial ...prophylaxis. The aim of this meta-analysis is to evaluate the usefulness of antibiotics in patients undergoing endoscopic mucosal or submucosal resections.
A comprehensive literature search of PubMed, MEDLINE, EMBASE, and Web of Science databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating the role of prophylactic antibiotic administration in reducing the PECS after endoscopic polypectomy were considered. The terms used to search were ("antimicrobial"OR"antibiotics"OR"prophylaxis"OR"prophylactic") AND ("resection"OR"polypectomy"OR"dissection") AND ("endoscopic"OR"mucosal"OR"submucosal") AND ("colon"OR"colorectal"OR"colonic"OR"rectum"). Data of included studies were collected and analysed.
The literature search revealed 262 articles, 3 of whom were randomized trials and one was a retrospective study. Patients included were 850 (548 treated with antibiotics and 302 received no treatment). The overall incidence rate was 2.4 and 19.9% in treatment and control groups, respectively. The pooled analysis showed a reduction of 83% of postoperative events in the antibiotics group (relative risk 0.181; 95% CI 0.100-0.326, p < 0.001).
In our meta-analysis, the antibiotic prophylaxis showed a positive effect in reducing the incidence of postoperative adverse events other than perforation and bleeding in patients treated with endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions. Despite the low-level of evidence of this meta-analysis, the antibiotic prophylaxis should be taken into account. Further multicenter, large-sample, randomized controlled studies are needed to confirm our results and to evaluate whether specific subgroups of patients could actually benefit from an antibiotic prophylaxis.
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