Over the past 2 decades, there has been an increase in opioid use and subsequently, opioid deaths. The amount of opioid prescribed to surgical patients has also increased. The aim of this systematic ...review was to determine postdischarge opioid consumption in surgical patients compared with the amount of opioid prescribed. Secondary outcomes included adequacy of pain control and disposal methods for unused opioids.
The objective of this study is to characterize postdischarge opioid consumption and prescription patterns in surgical patients.
A systematic search in MEDLINE and EMBASE identified 11 patient survey studies reporting on postdischarge opioid use in 3525 surgical patients.
The studies reported on a variety of surgical operations, including abdominal surgery, orthopedic procedures, tooth extraction, and dermatologic procedures. The majority of patients consumed 15 pills or less postdischarge. The proportion of used opioids ranged from 5.6% to 59.1%, with an outlier of 90.1% in pediatric spinal fusion patients. Measured pain scores of those taking opioids ranged between 2 and 5 out of 10 and the majority of patients were satisfied with their pain control. Seventy percent of patients kept the excess opioids. Where planned disposal methods were reported, between 4% and 59% of patients planned proper disposal.
This study suggests that surgical patients are using substantially less opioid than prescribed. There is a lack of awareness regarding proper disposal of leftover medication, leaving excess opioid that may be used inappropriately by the patient or others. Education for providers and clinical practice guidelines that provide guidance on prescription of outpatient of opioids are required.
Inflammatory complications following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are common and thought to arise through mechanisms similar to de novo onset inflammatory bowel ...disease. The aim of this study was to determine whether specific organisms in the tissue-associated microbiota are associated with inflammatory pouch complications.
Patients having previously undergone IPAA were recruited from Mount Sinai Hospital. Clinical and demographic information were collected and a pouchoscopy with biopsy of both the pouch and afferent limb was performed. Patients were classified based on post-surgical phenotype into four outcome groups: familial adenomatous polyposis controls (FAP), no pouchitis, pouchitis, and Crohn's disease-like (CDL). Pyrosequencing of the 16S rRNA V1-V3 hypervariable region, and quantitative PCR for bacteria of interest, were used to identify organisms present in the afferent limb and pouch. Associations with outcomes were evaluated using exact and non-parametric tests of significance.
Analysis at the phylum level indicated that Bacteroidetes were detected significantly less frequently (P<0.0001) in the inflammatory outcome groups (pouchitis and CDL) compared to both FAP and no pouchitis. Conversely, Proteobacteria were detected more frequently in the inflammatory groups (P=0.01). At the genus level, organisms associated with outcome were detected less frequently among the inflammatory groups compared to those without inflammation. Several of these organisms, including Bacteroides (P<0.0001), Parabacteroides (P≤2.2x10(-3)), Blautia (P≤3.0x10(-3)) and Sutterella (P≤2.5x10(-3)), were associated with outcome in both the pouch and afferent limb. These associations remained significant even following adjustment for antibiotic use, smoking, country of birth and gender. Individuals with quiescent disease receiving antibiotic therapy displayed similar reductions in these organisms as those with active pouch inflammation.
Specific genera are associated with inflammation of the ileal pouch, with a reduction of typically ubiquitous organisms characterizing the inflammatory phenotypes.
There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be ...associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone–induced pancreatitis. Une hausse de l’incidence de pancréatite aiguë a été constatée à l’échelle mondiale. Malgré l’amélioration de l’accès aux soins et aux techniques d’imagerie et d’intervention, la pancréatite aiguë est toujours associée à une morbidité et une mortalité importantes. Bien qu’il existe des guides de pratique clinique pour la prise en charge de la pancréatite aiguë, des études récentes sur la vérification de la prise en charge clinique de cette affection révèlent des lacunes importantes dans la conformité aux recommandations fondées sur des données probantes. Ces résultats mettent en relief l’importance de formuler des recommandations compréhensibles et applicables pour le diagnostic et la prise en charge de la pancréatite aiguë. La présente ligne directrice vise à fournir des recommandations fondées sur des données probantes pour la prise en charge de la pancréatite aiguë, qu’elle soit bénigne ou grave, ainsi que de ses complications et de celles de la pancréatite causée par un calcul biliaire.
Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which ...components have the greatest impact.
This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery.
An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery.
Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001).
Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.
Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes ...represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.
A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.
Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.
Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.
Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical ...patients.
ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow.
Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews.
Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential.
Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.
Background
Enhanced recovery after surgery programs have been introduced with aims of improving patient care, reducing complication rates, and shortening hospital stay following colorectal surgery. ...The aim of this meta-analysis was to determine whether enhanced recovery after surgery programs, when compared to traditional perioperative care, are associated with reduced primary hospital length of stay in adult patients undergoing elective colorectal surgery.
Methods
MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, and the reference lists were searched for relevant articles. Only randomized controlled trials comparing an enhanced recovery program with traditional postoperative care were included.
Results
Three of four included studies showed significantly shorter primary lengths of stay for patients enrolled in enhanced recovery programs. There was no significant difference in postoperative mortality when the two groups were compared relative risk (RR) = 0.53; 95% CI = 0.12–2.38; test for heterogeneity,
p
= 0.40 and
I
2
= 0, and patients in enhanced recovery programs were less likely to develop postoperative complications (RR = 0.61, 95% CI = 0.42–0.88; test for heterogeneity,
p
= 0.95 and
I
2
= 0).
Authors’ Conclusions
There is some evidence to suggest that enhanced recovery after surgery programs are better than traditional perioperative care, but evidence from a larger, better quality randomized controlled trial is necessary.
This study attempts to determine whether stapled side-to-side anastomosis, compared with handsewn end-to-end anastomosis, results in decreased recurrence of Crohn's disease following ileocolic ...resection.
Patients with Crohn's disease who underwent an ileocolic resection were randomized to side-to-side anastomosis or end-to-end anastomosis. Colonoscopy was performed at 12 months. The primary outcome was endoscopic recurrence, while the secondary outcome was symptomatic recurrence (defined as symptoms attributable to Crohn's disease and severe enough to warrant treatment, plus endoscopic disease recurrence).
One hundred and thirty-nine subjects were included in the efficacy analysis. After a mean follow-up of 11.9 months, the endoscopic recurrence rate was 42.5 percent in the end-to-end anastomosis group, compared with 37.9 percent in the side-to-side anastomosis group (-4.6 percent difference; 95 percent confidence interval -21.0 to 11.9 percent; P = 0.55). The symptomatic recurrence rate was 21.9 percent in the end-to-end anastomosis group, compared with 22.7 percent in the side-to-side anastomosis group (+0.8 percent difference; 95 percent confidence interval -13.2 to 15.3 percent; P = 0.92). In multivariate logistic regression analysis, previous resections were predictive of a higher risk of both endoscopic (odds ratio 1.78; 95 percent confidence interval 1.06 to 2.90; P = 0.028) and symptomatic (odds ratio 2.0; 95 percent confidence interval 1.14 to 3.60; P = 0.0016) recurrence. Compliance with postoperative maintenance therapy was predictive of a lower risk of symptomatic recurrence (odds ratio 0.13, 95 percent confidence interval 0.01 to 0.78; P = 0.021).
Recurrence rates are similar whether end-to-end anastomosis or side-to-side anastomosis is performed.
Objective
The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten ...hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals.
Methods
A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less.
Results
Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all
P
< 0.05). On multivariate analysis, factors that remained significantly associated with a stay ≤5 days included use of a laparoscopic approach (odds ratio (OR), 1.24; 95% confidence interval (CI), 1.12–1.38), preoperative counseling (OR, 1.26; 95% CI, 1.15–1.38), intraoperative fluid restriction (OR, 1.26; 95% CI, 1.15–1.37), clear fluids on day of surgery (OR, 1.09; 95% CI, 1.00–1.2), and Foley urinal catheter discontinued within 24 h of colon surgery and 72 h of rectal surgery (OR, 1.13; 95% CI, 1.01–1.27).
Conclusions
In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.
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