Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

High frequency oscillation in newborn infants with respiratory failure

Objective: To report ventilation strategies, survival and complications in 39 outborn infants treated with high frequency oscillatory ventilation (HFOV).
Methodology Data were collected prospectively between 1 May 1992 and 31 December 1993 on all infants treated with HFOV who had severe respiratory failure despite optimal conventional ventilation.
Results Twenty-eight out of 39 (72%) survived. Of the 15 infants with birthweights <1500g, eight survived. Best survival rates were for infants with pulmonary interstitial emphysema with air leak (4/5) and for infants of birthweight >1500g with hyaline membrane disease (8/8), and meconium aspiration syndrome (7/7). Three infants deteriorated while on HFOV and required extracorporeal membrane oxygenation. Complications were: (i) development of pulmonary interstitial emphysema (1); (ii) recurrence of pneumothorax (3); (iii) hypotension (2); and (iv) bronchopulmonary dysplasia (9). One of the eight infants weighing <1500g who received HFOV in the first week of life developed periventricular haemorrhage.
Conclusion The initial results of HFOV for severe respiratory failure were encouraging although a learning curve was encountered with its introduction.     

Dual-tracer scintigraphy and subtraction studies in the diagnosis of hepatocellular carcinoma

Dual tracer scintigraphy (DTS) (technetium 99m [99mTc] sulfur colloid and gallium 67 citrate [67 gallium citrate]) of the liver and computer subtraction studies (SS) were performed in 26 patients subsequently proven to have hepatocellular carcinoma (HCC) and 32 patients with cirrhosis and focal defects on the colloid scan, with no evidence for HCC after a complete evaluation and a 2-year follow-up period. Both DTS and SS had a sensitivity of 96% and a specificity of 90.6% for HCC. There were three false positive cases (9.4%), two of which were occult abscesses. The predictive value of a positive test was 89% and that of a negative test was 97%. The smallest tumor detected measured 2 cm in diameter and was only visualized with the SS. In the clinical setting, when HCC is suspected (a situation in which tumors are usually larger than 2 cm and the pretest probability of disease is between 20% and 60%) the DTS and SS is an excellent test for the diagnosis or exclusion of HCC. It does not appear to have a role in screening programs.     

Reoperation for dysfunction of the Björk-Shiley mitral disc prosthesis: Report of eight cases

Of 193 patients with Bj?rk-Shiley mitral valve prostheses, replacement was necessary in 8 (4.1%). The reasons for reoperation were: detachment (4), thrombosis (1), technical error (1), and late disc entrapment (2). Five of these patients died (62.5%), the death being directly related to the need for urgent operation because of low cardiac output. We recommend avoiding the use of the larger sized Bj?rk-Shiley prostheses, since striking of the disc against the ventricle wall, probably consequent to postoperative decrease in heart size, may appear even 1 year after implantation of the prosthesis. An early diagnosis and early reoperation offer these patients a much more favorable prognosis.     

Adenovirus and respiratory syncytial virus-adenovirus mixed acute lower respiratory infections in Chilean infants

BACKGROUND: In Chile respiratory syncytial virus (RSV) and adenovirus (AD) are the principal viruses detected in acute lower respiratory infections (ALRI) in infants. An overview of AD pneumonia in Chile to detect annual trends and to compare the severity of single AD or mixed RSV-AD infections is presented. METHODS: Surveillance in 4927 infants hospitalized for ALRI has been performed from 1989 to 2001 using immunofluorescence assay (IFA) and viral isolation. Clinical features in 117 infants with single genotyped AD and 81 infants with mixed RSV-AD infections were analyzed. RESULTS: Adenovirus cases declined from 20% annually in the early 1990s to approximately 5% in the 2000 decade. Genotype 7h showed increasing prevalence in hospitalized cases. The mean annual burden of hospitalizations caused by AD in Santiago was estimated to be 0.6%. No difference was observed in duration of fever, oxygen requirement and hospital stay between groups. Lung consolidation was more frequent in AD cases than mixed cases (P < 0.01); interstitial pattern and hyperinflation prevailed in the mixed cases (P < 0.01). No child died. AD diagnosis was confirmed on admission by IFA in 17% of cases of RSV-AD and in 43% of cases of single AD ALRI. AD cases diagnosed early by IFA had worse clinical outcome than those diagnosed later by virus isolation (P < 0.05). CONCLUSIONS: AD cases declined since 1989. Mixed RSV-AD infections were not more severe than single AD etiology. AD cases admitted with positive IFA had worse prognoses than AD infections diagnosed later by virus isolation.     

A rapid agglutination assay to detect anti-streptokinase antibodies

Background Streptokinase resistance may cause suboptimal thrombolytic therapy. Aim To develop a rapid latex-bead assay to detect streptokinase antibodies. Methods Sera were obtained from 16 patients presenting with acute myocardial infarction (MI) before treatment with streptokinase and 1 and 6 months post treatment, and from 100 controls. Sera were assayed for anti-streptokinase antibodies using a functional streptokinase-neutralising assay. Results Streptokinase-neutralising activity was low in controls (54±5U/ml) and patients prior to treatment (101±18), increasing to 2,110±823 and 1,017±169 at 1 and 6 months (mean±SEM). The latex assay had a sensitivity of 94% and a specificity of 93% for detecting individuals with >350U/ml of streptokinase resistance, which is sufficient to neutralise the drug clinically. Conclusions Estimation of streptokinase resistance using an enzyme immunoassay and a latex bead assay correlated well with serum neutralising activity. This assay can rapidly identify patients who have a high level of streptokinase-neutralising activity.     

Effectiveness of a disease management program for patients with diabetes

Diabetes disease management programs (DDMPs) are proliferating, but their effectiveness in improving quality and mitigating health care spending has been difficult to measure. Using two quasi-experimental methods, this study analyzed the first-year results of a multistate DDMP for people with diabetes sponsored by a national managed care organization. In both analyses, overall cost of care were significantly lower in DDMP sites, and the payer saved more than it spent. Pharmacy costs showed mixed results. Quality scores in the DDMP sites were significantly better than in sites without the program.