Introduction of an enhanced recovery protocol for radical cystectomy

OBJECTIVE

To describe and assess an enhanced recovery protocol (ERP) for the peri‐operative management of patients undergoing radical cystectomy (RC), which was started at our institution on 1 October 2005, as RC is associated with increased morbidity and longer inpatient stays than other major urological procedures.

PATIENTS AND METHODS

An ERP was introduced in our institution that focused on reduced bowel preparation, and standardized feeding and analgesic regimens. In all, 112 consecutive patients were compared, i.e. 56 before implementing the ERP and 56 since introducing the ERP. The primary outcome measures were duration of total inpatient stay and interval from surgery to discharge, and the morbidity and mortality. Data were analysed retrospectively from cancer network and hospital records.

RESULTS

The demographics of the two groups showed no significant difference in age, gender distribution, American Society of Anesthesiologists grade, or type of urinary diversion. Re‐admission, mortality and morbidity rates showed no statistically significant difference between the groups. The median (interquartile range) duration of hospital stay was 17 (15–23) days in the no‐ERP group, and 13 (11–17) days in the ERP group (significantly different, P < 0.001, Wilcoxon rank‐sum test). The median duration of recovery after RC was 15 (13–21) days in the no‐ERP group and 12 (10–15) days in the ERP group (significantly different, P = 0.001, Wilcoxon rank‐sum test).

CONCLUSION

The introduction of an ERP was associated with significantly reduced hospital stay, with no deleterious effect on morbidity or mortality.     

Improvement of an enhanced recovery protocol for radical cystectomy

IntroductionEnhanced recovery protocols (ERPs) aim to improve outcome following major abdominal surgery. Our ERP for radical cystectomy focuses on reduced bowel preparation and standardised feeding and analgesic regimens. Although the ERP safely decreased hospital stay, time to return of bowel function has not been affected. The current study aims to assess the addition of chewing gum on return of bowel function as part of an ERP.Patients and methodsWe examined the addition of chewing gum to our ERP. Data was obtained retrospectively from 112 consecutive patients, 56 before and 56 after implementing chewing gum in to the EPR. The primary outcome measured was return of bowel function signified by first defecation after surgery.ResultsThe demographics of the two groups showed no significant difference in age, gender distribution, American Society of Anesthesiologists grade, or type of urinary diversion. A significant reduction in the time to return of bowel function was observed in patients using chewing gum post-operatively (4 versus 6 days, p < 0.0001). The median inpatient stay was 13 days in both groups; however there was a trend to an earlier discharge in those patients receiving chewing gum.ConclusionThe introduction of chewing gum to our ERP is associated with a faster return of bowel function and may lead to a reduced inpatient stay.     

Implementation of an enhanced recovery protocol in pediatric colorectal surgery

Purpose

Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery.

Cost–utility analysis of an advanced pressure ulcer management protocol followed by trained wound,ostomy, and continence nurses

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost‐effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1‐year time horizon to determine the incremental cost‐effectiveness ratio of advanced PU management compared with conventional care. The number of quality‐adjusted life‐years gained, and the cost in Japanese yen (¥) ($US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost‐effective than conventional care.     

加速康复外科在腹腔镜胰十二指肠切除术中的应用

目的 评估加速康复外科（enhanced recovery after surgery,ERAS）在腹腔镜下胰十二指肠切除术（laparoscopic pancreatoduodenectomy,LPD）围手术期的临床应用价值。方法 回顾性分析2016年1月至2018年1月河南省人民医院收治的79例行LPD的患者临床资料,其中围手术期采用ERAS处理方案的患41例（ERAS组）,采用传统处理方案的患者38例（传统组）。比较分析两组患者围手术期相关参数。结果 ERAS组的术后AST[（110.38±102.43）U/L]和术后血肌酐[（61.20±16.46）μmol/L]均较传统组轻[（427.09±1 434.66）U/L,（74.28±49.58）μmol/L,均P＜0.05）;住院时间[（17.29±5.44）d]较传统组[（24.68±13.28）d]短（P＜0.05）。ERAS组术后总并发症发生率、腹腔出血及肺部感染发生率均明显低于传统组（P＜0.05）。ERAS组绝大部分患者（90.4%）的术后并发症可自愈,而传统组近一半（48.5%）的术后并发症需干预处理（P＜0.05）。结论 LPD围手术期实施ERAS方案能减少患者肝肾功能损害,降低并发症发生率,缩短住院时间,促进患者早日康复。     

Randomized clinical trial of goal‐directed fluid therapy within an enhanced recovery protocol for elective colectomy

Background:

Goal‐directed fluid therapy (GDFT) has been compared with liberal fluid administration in non‐optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.

Methods:

Patients undergoing elective laparoscopic or open colectomy within an established enhanced recovery protocol (including fluid restriction) were randomized to GDFT or no GDFT. Bowel preparation was permitted for left colonic operations at the surgeon's discretion. Exclusion criteria included rectal tumours and stoma formation. The primary outcome was a patient‐reported surgical recovery score (SRS). Secondary endpoints included clinical outcomes and physiological measures of recovery.

Results:

Eighty‐five patients were randomized, and there were 37 patients in each group for analysis. Nine patients in the GDFT and four in the fluid restriction group received oral bowel preparation for either anterior resection (12) or subtotal colectomy (1). Patients in the GDFT group received more colloid during surgery (mean 591 versus 297 ml; P = 0·012) and had superior cardiac indices (mean corrected flow time 374 versus 355 ms; P = 0·018). However, no differences were observed between the GDFT and fluid restriction groups with regard to surgical recovery (mean SRS after 7 days 47 versus 46 respectively; P = 0·853), other secondary outcomes (mean aldosterone/renin ratio 9 versus 8; P = 0·898), total postoperative fluid (median 3750 versus 2400 ml; P = 0·604), length of hospital stay (median 6 versus 5 days; P = 0·570) or number of patients with complications (26 versus 27; P = 1·000).

Conclusion:

GDFT did not provide clinical benefit in patients undergoing elective colectomy within a protocol incorporating fluid restriction. Registration number: NCT00911391 ( http://www.clinicaltrials.gov ). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

A protocol is not enough to implement an enhanced recovery programme for colorectal resection

BACKGROUND: Single-centre studies have suggested that enhanced recovery can be achieved with multimodal perioperative care protocols. This international observational study evaluated the implementation of an enhanced recovery programme in five European centres and examined the determinants affecting recovery and length of hospital stay. METHODS: Four hundred and twenty-five consecutive patients undergoing elective open colorectal resection above the peritoneal reflection between January 2001 and January 2004 were enrolled in a protocol that defined multiple perioperative care elements. One centre had been developing multimodal perioperative care for 10 years, whereas the other four had previously undertaken traditional care. RESULTS: The case mix was similar between centres. Protocol compliance before and during the surgical procedure was high, but it was low in the immediate postoperative phase. Patients fulfilled predetermined recovery criteria a median of 3 days after operation but were actually discharged a median of 5 days after surgery. Delay in discharge and the development of major complications prolonged length of stay. Previous experience with fast-track surgery was associated with a shorter hospital stay. CONCLUSION: Functional recovery in 3 days after colorectal resection could be achieved in daily practice. A protocol is not enough to enable discharge of patients on the day of functional recovery; more experience and better organization of care may be required.     

加速康复外科理念在胰十二指肠切除术围手术期中的疗效分析

目的探讨使用加速康复外科(ERAS)理念指导胰十二指肠切除术(PD)围术期的安全性与可行性。方法回顾性分析2014年6月至2019年6月行PD的44例患者的临床资料,其中24例患者采用ERAS理念行围术期管理(ERAS组),20例患者运用传统观念行围术期管理(传统组),采用SPSS 19.0软件进行统计分析。术中术后各项指标采用(±s)表示,独立t检验;术后并发症采用χ^2检验,P<0.05为差异有统计学意义。结果两组患者术中出血量、手术时长差异无统计学意义(P>0.05),ERAS组术后胃肠道通气时间,术后平均住院时间,住院费用,术后24 h、48 h疼痛评分显著低于传统组,而患者满意度显著高于传统组,差异均有统计学意义(P<0.05)。ERAS组共发生并发症5例(20.8%),明显少于传统组并发症10例(50%),差异有统计学意义(P<0.05)。结论运用加速康复外科模式行PD围手术期管理安全有效,具有患者花费少,手术恢复快,术后并发症少的优势,值得临床推广。     

加速康复外科理念在胰十二指肠切除术围手术期的应用

目的:探讨加速康复外科(ERAS)理念在胰十二指肠切除术(PD)围手术期的临床应用价值。方法:回顾性分析郑州大学附属肿瘤医院2015年6月—2016年12月行根治性PD治疗42例患者的临床资料,所有患者围手术期均采用ERAS措施,记录术后并发症、住院时间及再入院情况等。结果:术后第1天,所有患者行常规尿管拔除,2例因前列腺增生再次留置,22例(52.4%)患者下床活动,10例(23.8%)达预定活动标准;术后第2天,常规拔除胃管,5例因发生胃排空延迟重新留置胃管,30例(71.4%)耐受流质饮食;术后第3天,35例(83.3%)拔除腹腔引流管;术后第4天,33例(78.6%)固体饮食。术后胰瘘3例,胆汁漏1例,出血1例,腹腔积液3例,胃排空延迟4例,肺部感染1例,术后总体并发症发生率31.0%,均经对症治疗治愈,无死亡病例。中位住院时间10(8~35)d。术后30d再入院3例(7.1%),其中胃功能不全1例,腹腔积液并感染1例,胆道感染1例。结论:ERAS理念在PD围手术期的应用安全可行,能缩短住院时间的同时不增加术后并发症发生率和再入院率。     

快速康复外科在胰十二指肠切除术围术期管理中的应用价值

背景与目的:近年来,快速康复外科(ERAS)理念已在许多外科领域推广应用,并取得了显著成效.然而ERAS在胰十二指肠切除术(PD)围术期的应用仍然有限.本研究通过前瞻性临床分析,探讨ERAS在PD围术期管理中的应用价值.方法:前瞻性连续收集2017年12月-2019年9月间中南大学湘雅医院胰腺外科收治的101例行PD患...     

加速康复外科理念在胰十二指肠切除术围手术期的应用

目的 观察加速康复外科(enhanced recovery after surgery,ERAS)措施在胰十二指肠切除术围手术期应用的效果,总结在ERAS指导下的围手术期多模式镇痛、营养干预、呼吸道管理、血栓预防等护理措施对患者术后康复的影响.方法 回顾性分析温州医科大学附属第一医院2019年5月到2020年7月肝胆外...     

Enhanced recovery after surgery pathways benefit patients with soft pancreatic texture following pancreaticoduodenectomy

BackgroundWe aimed to compare the enhanced recovery after surgery pathway with the standard perioperative care protocol concerning complications, postoperative length of stay and 1-year survival rate.MethodsUsing a before–after cohort study design, data from patients with pancreatic head cancer, who consecutively underwent pancreaticoduodenectomy, were retrospectively collected.ResultsCompared to the control group, patients with soft pancreas in the enhanced recovery after surgery group had a lower incidence of delayed gastric emptying (36.7% vs 13.3%, P = 0.026) and respiratory complications (46.7% vs 20.0%, P = 0.028), and shorter postoperative length of stay (All: 10.9 ± 3.4 d vs13.5 ± 3.8 d, P = 0.002; Soft: 11.2 ± 3.8 d vs14.0 ± 4.5 d, P = 0.001). The 1-year survival rates were similar between the groups.ConclusionThe enhanced recovery after surgery pathways can significantly reduce the incidence of certain surgical complications and decrease the postoperative length of stay. It does not affect 1-year survival.