Depression Is Associated with Prolonged and Complicated Recovery Following Colorectal Surgery

Background  

There are little data regarding the impact of depression on outcomes after gastrointestinal surgery. We hypothesize that depression would be associated with prolonged hospital stay and changes in discharge disposition for patients undergoing colon and rectal surgery.     

Time to Readiness for Discharge is a Valid and Reliable Measure of Short-Term Recovery After Colorectal Surgery

Background

Short-term recovery after colorectal surgery has been traditionally investigated through length of stay (LOS). However, this measure is influenced by several confounding factors. This study aimed to investigate the construct validity and reliability of assessing the time to achieve standardized discharge criteria (time to readiness for discharge, or TRD) as a measure of short-term recovery. In a secondary analysis, we compared sample size requirements for randomized controlled trials (RCTs) using TRD or LOS as outcome measures.

Methods

Seventy patients participated in the construct validity study and 21 patients participated in the reliability study. TRD was defined as the number of days to achieve discharge criteria previously defined by consensus. Construct validity was investigated by testing six hypothesis based on the assumption that TRD measures short-term recovery. Reliability was calculated by comparing measures of TRD by two independent assessors. Variability estimates (standard deviations) of LOS and TRD were used for sample size calculations.

Results

Five of the six hypotheses were supported by the data (p < 0.05). Interobserver reliability was excellent (ICC_2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23 % less participants compared to RCTs using LOS.

Conclusions

The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using TRD as an alternative to LOS may reduce sample size requirements in future RCTs.     

Time-Driven Activity-Based Costing to Model Cost Utility of Enhanced Recovery after Surgery Pathways in Microvascular Breast Reconstruction

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Delay to Curative Surgery Greater than 12 Weeks Is Associated with Increased Mortality in Patients with Colorectal and Breast Cancer but Not Lung or Thyroid Cancer

Background

Surgery for cancer is often delayed due to variety of patient-, provider-, and health system–related factors. However, impact of delayed surgery is not clear, and may vary among cancer types. We aimed to determine the impact of the delay from cancer diagnosis to potentially curative surgery on survival.

Methods

Cohort study based on representative sample of patients (n = 7,529) with colorectal, breast, lung and thyroid cancer with local or regional disease who underwent potentially curative surgery as their first therapeutic modality within 1 year of cancer diagnosis. They were diagnosed in 2006 and followed for mortality until April 2011, a median follow-up of 4.7 years.

Results

For colorectal and breast cancers, the adjusted hazard ratios (95 % confidence intervals) for all-cause mortality comparing a surgical delay beyond 12 weeks to performing surgery within weeks 1–4 after diagnosis were 2.65 (1.50–4.70) and 1.91 (1.06–3.49), respectively. No clear pattern of increased risk was observed with delays between 4 and 12 weeks, or for any delay in lung and thyroid cancers. Concordance between the area of the patient’s residence and the hospital performing surgery, and the patient’s income status were associated with delayed surgery.

Conclusions

Delays to curative surgery beyond 12 weeks were associated with increased mortality in colorectal and breast cancers, suggesting that health provision services should be organized to avoid unnecessary treatment delays. Health care systems should also aim to reduce socioeconomic and geographic disparities and to guarantee equitable access to high quality cancer care.     

Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components

BackgroundEnhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes.MethodsThis retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, “any complication,” and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.ResultsIn 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of “any complication” (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of “any complication” (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes.ConclusionDespite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized.Level of EvidenceIII.     

目标管理在胰腺肿瘤患者围手术期快速康复的实践

目的探讨目标管理在胰腺肿瘤围手术期患者快速康复的实践效果。方法按时间段将行胰腺肿瘤手术的88例患者分为对照组,另47例患者分为观察组。对照组采用常规围手术期护理措施,观察组由研究小组基于快速康复理念建立并按照目标达成进行管理。结果与对照组相比,观察组术后首次进食时间、首次下床时间及住院时间显著缩短(P0.05,P0.01)。结论目标管理应用于胰腺肿瘤围手术期患者,有助于完成快速康复内容,缩短下床时间,减少患者住院时间,促进术后快速康复。