Background
Enhanced recovery after surgery (ERAS) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications, costs and hospital stay. ...This concept has been applied for pancreatic surgery since the first published guidelines in 2012. This study presents the updated ERAS recommendations for pancreatoduodenectomy (PD) based on the best available evidence and on expert consensus.
Methods
A systematic literature search was conducted in three databases (Embase, Medline Ovid and Cochrane Library Wiley) for the 27 developed ERAS items. Quality of randomized trials was assessed using the Consolidated Standards of Reporting Trials statement checklist. The level of evidence for each item was determined using the Grading of Recommendations Assessment Development and Evaluation system. The Delphi method was used to validate the final recommendations.
Results
A total of 314 articles were included in the systematic review. Consensus among experts was reached after three rounds. A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay. The highest level of evidence was available for five items: avoiding hypothermia, use of wound catheters as an alternative to epidural analgesia, antimicrobial and thromboprophylaxis protocols and preoperative nutritional interventions for patients with severe weight loss (> 15%).
Conclusions
The current updated ERAS recommendations for PD are based on the best available evidence and processed by the Delphi method. Prospective studies of high quality are encouraged to confirm the benefit of current updated recommendations.
To assess the safety and efficacy of liver venous deprivation (simultaneous hepatic vein embolization with portal vein embolization) compared with portal vein embolization alone before major ...hepatectomy in patients with small future liver remnant.
We assessed all consecutive patients who underwent ipsilateral liver venous deprivation before major hepatectomy (>4 Couinaud’s segments) at the University Hospital Lausanne from 2016 to 2018. Postembolization, volumetric analysis after liver venous deprivation and postoperative outcomes were compared with patients who underwent portal vein embolization alone (portal vein embolization group) from 2010 to 2016.
During the study period, 21 patients underwent liver venous deprivation and 39 portal vein embolization alone. In the liver venous deprivation versus portal vein embolization groups, dropout rate owing to disease progression was 1 of 21 vs 9 of 39 (P = .053). There were no per procedural complications after liver venous deprivation and no difference in the postoperative outcomes. Future liver remnant hypertrophy was greater in the liver venous deprivation group (median 135%, interquartile range: 123%–154%) than in the portal vein embolization group (median 124%, interquartile range: 107%–140%) at a median time of 22 days after liver venous deprivation vs 26 days after portal vein embolization (P = .034). The median kinetic growth rate was also greater (2.9%/week, interquartile range: 1.9–4.3% vs 1.4%/week, interquartile range: 0.7–2.1%; P < .001).
Ipsilateral liver venous deprivation before major hepatectomy is safe and seems to induce a greater and faster future liver remnant hypertrophy than after portal vein embolization alone. More data are needed to analyze the impact of liver venous deprivation on tumor growth.
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.
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
Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in ...colorectal, pancreas, and liver surgery induce cost savings.
Methods
A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS
®
, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.
Results
Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370–650,
p
= 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600–2430,
p
= 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.
Conclusions
The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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.
Background
Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ...ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.
Methods
A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.
Results
A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.
Conclusions
These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
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