Background
The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience.Study Design
All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991–1996, Gp2 1997–2002, Gp3 2003–2007, and Gp4 2008–2012).Results
Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5–50) to 8 (5–115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively.Conclusions
The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy. 相似文献Background
Enhanced Recovery Programmes (ERPs) have been shown to benefit recovery following major surgery in selected centres and patient groups, but their wider applicability requires continued evaluation. The aims of this study were to assess the outcomes of the first 400 consecutive, non-selected patients, undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes.Methods
Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospectively on a database. Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective, pre-ERP group; and according to patient risk factors and operative approaches.Results
Median length of stays (LOS) reduced from 9 days (IQR 7–11) to 6 days (IQR 5–10) after introduction of the ERP (p < 0.001). No statistically significant differences in LOS were observed between elderly (≥80 years) and younger patients or between different BMI groups. American Society of Anesthesiologists (ASA) grade 3 patients demonstrated significantly longer median LOS than those with ASA grades 1 and 2. Patients undergoing laparoscopic surgery had median LOS of 6 days (IQR 4–8) compared to 7 days (IQR 5–10) for open procedures (p < 0.001). No differences in morbidity or mortality were observed between the groups.Conclusions
Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS. The ERP was safe and effective when applied to all our study patients independent of age and BMI. Despite LOS being longer in ASA grade 3 patients, application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality. Laparoscopic surgery resulted in additional modest reductions in LOS compared to open surgery within the ERP. 相似文献Methods: The authors validated UIA as an indicator of safety in surgical patients in a prospective cohort study of 44,130 patients admitted to their hospital. They assessed the association of UIA with intraoperative incidents and near misses, increased hospital length of stay, and 30-day mortality as three constructs of patient safety.
Results: The authors identified 201 patients with a UIA; 104 (52.2%) had at least one incident or near miss. After adjusting for confounders, these incidents were significantly associated with UIA in all categories of surgical procedures analyzed; odds ratios were 12.21 (95% confidence interval [CI], 6.33-23.58), 4.06 (95% CI, 2.74-6.03), and 2.13 (95% CI, 1.02-4.42), respectively. The 30-day mortality for patients with UIA was 10.9%, compared with 1.1% in non-UIA patients. After risk adjustment, UIA was associated with excess mortality in several types of surgical procedures (odds ratio, 3.89; 95% CI, 2.14-7.04). The median length of stay was increased if UIA occurred: 16 days (interquartile range, 10-31) versus 2 days (interquartile range, 0.5-9) (P < 0.001). For patients with a UIA, the likelihood of discharge from hospital was significantly decreased in most surgical categories analyzed, with adjusted hazard ratios of 0.41 (95% CI, 0.23-0.77) to 0.58 (95% CI, 0.37-0.93). 相似文献