Background Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, ...complications, and readmissions. Methods Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. Results We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 interquartile range (IQR), 5–7 vs 7 6–10 days; P < .05), total complications (40 37% vs 64 50%; P < .05), urinary tract infections (3 3% vs 15 12%; P < .05), and chest tube duration (median, 4 IQR, 3–6 vs 5 4–7 days; P < .05), with no difference in readmissions (7 7% vs 6 5%; P < .05) or chest tube reinsertion (4 4% vs 6 5%; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 IQR, 4–6 vs 6 5–7 days; P < .05). Conclusion Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.
Purpose Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. ...The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy. Methods Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values interquartile range. Results We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 7–17 vs 10 9–17 days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%). Conclusion Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.
Background Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and ...decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy. Study Design Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items. Results A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 range 8 to 14). One hundred eight cognitive elements (35 32% related to situation awareness, 47 44% involving decision-making, and 26 24% action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 32%), decision-making (49 65%), or either one (61 81%). Conclusions This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety.
Background Early mobilization is considered an important element of postoperative care; however, how best to implement this intervention in clinical practice is unknown. This systematic review ...summarizes the evidence regarding the impact of specific early mobilization protocols on postoperative outcomes after abdominal and thoracic surgery. Method The review was performed according to PRISMA guidelines. We searched 8 electronic databases to identify studies comparing patients receiving a specific protocol of early mobilization to a control group. Methodologic quality was assessed using the Downs and Black tool. Results Four studies in abdominal surgery (3 randomized controlled trials RCTs and 1 observational prospective study) and 4 studies in thoracic surgery (3 RCTs and 1 observational retrospective study) were identified. None of the 5 studies evaluating postoperative complications reported differences between groups. One of 4 studies evaluating duration of stay reported a significant decrease in the intervention group. One of 3 studies evaluating gastrointestinal function reported differences in favor of the intervention group. One of 4 studies evaluating performance-based outcomes reported differences in favor of the intervention group. One of 5 studies evaluating patient-reported outcomes reported differences in favor of the intervention group. Overall methodologic quality was poor. Conclusion Few comparative studies have evaluated the impact of early mobilization protocols on outcomes after abdominal and thoracic surgery. The quality of these studies was poor and results were conflicting. Although bed rest is harmful, there is little available evidence to guide clinicians in effective early mobilization protocols that increase mobilization and improve outcomes.
Background Evidence suggests that multimodal prehabilitation programs comprising interventions directed at physical activity, nutrition, and anxiety coping can improve functional recovery after ...colorectal cancer operations; however, such programs may be more clinically meaningful and cost-effective if targeted to specific subgroups. This study aimed to estimate the extent to which patients with poor baseline functional capacity improve their functional capacity. Methods Data for 106 participants enrolled in a multimodal, prehabilitation program before colorectal operations were analyzed. Low baseline functional capacity was defined as a 6-minute walking test distance (6MWD) of less than 400 m. Participants were categorized as higher fitness (6MWD ≥ 400 m, n = 70) or lower fitness (6MWD <400 m, n = 36). Changes in 6MWD over the preoperative period, and 4 weeks and 8 weeks after the operation were compared between groups. Secondary outcomes included patient-reported physical activity and health status, postoperative complications, duration of hospital stay, and readmissions. Less-fit patients were then compared with subjects in the rehabilitation arm of the original studies who had a baseline 6MWD <400 m. Results Participants with lower baseline fitness had greater improvements in functional walking capacity with prehabilitation compared to patients with higher fitness (+46.5 standard deviation 53.8 m vs +22.6 standard deviation 41.8 m, P = .012). At 4 weeks postoperatively, patients with lower baseline fitness were more likely to be recovered to their baseline 6MWD than those with higher fitness. (74% vs 50%, P = .029). There were no differences in secondary outcome. Less-fit patients had a greater improvement through all the preoperative period compared to the control group. Conclusion Patients with lower baseline walking capacity are more likely to experience meaningful improvement in physical function from prehabilitation before and after a colorectal cancer operation.
Background In the general population, high serum uric acid concentration is a risk factor for gout. It is unknown whether donating a kidney increases a living donor’s risk of gout as serum uric acid ...concentration increases in donors after nephrectomy. Study Design Retrospective matched cohort study using large health care databases. Setting & Participants We studied living kidney donors who donated in 1992 to 2010 in Ontario, Canada. Matched nondonors were selected from the healthiest segment of the general population. 1,988 donors and 19,880 matched nondonors were followed up for a median of 8.4 (maximum, 20.8) years. Predictor Living kidney donor nephrectomy. Outcomes The primary outcome was time to a diagnosis of gout. The secondary outcome in a subpopulation was receipt of medications typically used to treat gout (allopurinol or colchicine). Measurements We assessed the primary outcome with health care diagnostic codes. Results Donors compared with nondonors were more likely to be given a diagnosis of gout (3.4% vs 2.0%; 3.5 vs 2.1 events/1,000 person-years; HR, 1.6; 95% CI, 1.2-2.1; P < 0.001). Similarly, donors compared with nondonors were more likely to receive a prescription for allopurinol or colchicine (3.8% vs 1.3%; OR, 3.2; 95% CI, 1.5-6.7; P = 0.002). Results were consistent in multiple additional analyses. Limitations The primary outcome was assessed using diagnostic codes in health care databases. Laboratory values for serum uric acid and creatinine in follow-up were not available in our data sources. Conclusions The findings suggest that donating a kidney modestly increases an individual’s absolute long-term incidence of gout. This unique observation should be corroborated in future studies.
Abstract Objective Enhanced-recovery pathways aim to accelerate postoperative recovery and facilitate early hospital discharge. The aim of this systematic review was to summarize the evidence ...regarding the influence of this intervention in patients undergoing lung resection. Methods The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Eight bibliographic databases (Medline, Embase, BIOSIS, CINAHL, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched for studies comparing postoperative outcomes in adult patients treated within an enhanced-recovery pathway or traditional care. Risk of bias was assessed using the Cochrane Collaboration risk of bias tool. Results Six studies fulfilled our selection criteria (1 randomized and 5 nonrandomized studies). All the nonrandomized studies reported shorter length of stay in the intervention group (difference, 1.2-9.1 days), but the randomized study reported no differences. There were no differences between groups in readmissions, overall complications, and mortality rates. Two nonrandomized studies reported reduction in hospital costs in the intervention group. Risk of bias favoring enhanced recovery pathways was high. Conclusions A small number of low-quality comparative studies have evaluated the influence of enhanced-recovery pathways in patients undergoing lung resection. Some studies suggest that this intervention may reduce length of stay and hospital costs, but they should be interpreted in light of several methodologic limitations. This review highlights the need for well-designed trials to provide conclusive evidence about the role of enhanced-recovery pathways in this patient population.
Abstract Background As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of ...these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. Methods Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. Results A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. Conclusions Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.
Evaluation and stages of surgical innovations Barkun, Jeffrey S, Prof; Aronson, Jeffrey K, Prof; Feldman, Liane S, MD ...
The Lancet (British edition),
2009-Sep-26, Letnik:
374, Številka:
9695
Journal Article
Recenzirano
Summary Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and ...adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.
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