Non-invasive approaches to living donor nephrectomy: Best practices and innovations.

Enhanced recovery: joining the dots

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

Enhanced recovery after surgery (ERAS) reduces complications and shortens hospital stay without increasing readmission or mortality. However, its role in living donor nephrectomy (LDN) has not yet been defined. Medline, Embase, CINAHL, PsycINFO, and Cochrane Central were searched prior to 08/01/21 for all randomized controlled and cohort studies comparing ERAS to standard of care in LDN. The study was registered on PROSPERO (CRD: CRD42019141706). One thousand, three hundred seventy-seven patients were identified from 14 studies (698 patients with ERAS and 679 patients without). There were considerable differences in the protocols used, and compliance with general ERAS recommendations was poor. Meta-analysis of laparoscopic procedures (including hand- and robot-assisted) revealed that duration of stay was significantly reduced by 0.98days with ERAS (95% CI=0.36-1.60, P=.002) and opiate requirement by 32.4mg (95% CI=1.1-63.7, P=.04). There was no significant difference n readmission rates or complications. Quality of evidence was low to moderate assessed using the GRADE tool. This review suggests there is a positive benefit of ERAS in laparoscopic LDN. However, there was considerable variation in ERAS protocols used, and the quality of evidence was low; as such, a guideline for ERAS in LDN should be developed and validated.

Background: Open gastrectomy with lymphadenectomy has been a preferred surgical method worldwide for a long time. However, this procedure is associated with clinically significant postoperative stress, high morbidity, rate (9.1-46.0%) and longer hospital stay. Several meta-analyses have shown better short-term results after laparoscopic gastrectomy compared to an open procedure, with similar oncological outcomes. Patients with resectable gastric cancer were included in this study. Enhanced recovery after surgery (ERAS) programs have been proposed to maintain physiological function and facilitate postoperative recovery. In the following studies, laparoscopic gastrectomy was considered to reduce the rates of morbidity and shorten the length of the hospital stay. Materials and Metods: This study was a non-randomized prospective trial. Patients with histologically proven, surgically resectable gastric cancer (T1- 4a,N1-3b, M0) and European Oncology Study Group performance status 0,1,2 were eligible to participate in this study. We applied an ERAS program in the laparoscopic surgery group and in the open gastrectomy group. The primary endpoints were operative time and morbidity rate. The second factors were length of hospital stay and cost-effectiveness. Additionally, we focused on the standardized operative technique. For the period March 1, 2014-January 31, 2015, 36 patients underwent laparoscopic gastric resection for gastric cancer. We performed 17 total D2 gastrectomies with esophagojejunal anastomosis and 12 subtotal gastrectomies with gastrojejonoanastomosis. We also performed 48 open gastrectomies (30 total and 18 subtotal ones) for this period. In all patients, the ERAS protocol was implemented. Results: The mean duration of the laparoscopic procedure was 210 min. versus 150 min in open group. There was 1 conversion due to a mesenterial lipoma as a reason for a short jejunal lооp. The mean hospital stay was 5.6 days in the laparoscopic group and 9.4 days in the open group. Two postoperative complications (7.1%) after a laparoscopic procedure (internal pancreatic fistula, leakage of oesophagojejunal anastomosis ) were reported. Three postoperative complications (7.1%) after an open surgery (duodenal stump leakage, external pancreatic fistula with bleeding, leakage from oesophagojejunal anastomosis) were found. All of patients with postoperative complication had an advanced stage gastric cancer (T3-4aN1- 3bM0).Conclusion: The implementation of the ERAS protocol in the clinical practice in combination with laparoscopy in patients with gastric cancer can result in improved post-operative care quality, shortening of the hospital stay, and quicker return to normal activity. We did not find significant differences in the morbidity rate between laparoscopic and open-operated patients. Perhaps, we have not analyzed the entire learning curve of the laparoscopic gastric surgery.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

Enhanced recovery after surgery protocols are multimodal perioperative care pathways shown to improve postoperative complications and decrease the length of stay after surgery. A critical component of an enhanced recovery after surgery protocol is the use of multimodal nonopiate analgesia using nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors. To compare the incidence of postoperative GI bleeding between patients treated with and without an enhanced recovery after surgery protocol. Retrospective review of a prospectively maintained colorectal registry. Large colorectal referral center. Preoperative elective colorectal surgery requiring an anastomosis. Standardized enhanced recovery after surgery protocol included celecoxib and ketorolac. Postoperative outcomes included bleeding (±sequelae), reduction in hematocrit after the operation, intervention for bleeding (transfusion, endoscopy, or surgery), length of stay, and hospital readmission. The enhanced recovery after surgery group (n = 630) and nonenhanced recovery after surgery group (n = 739) were comparable in baseline clinical features except for surgical indication, with more IBD and less malignant disease in the enhanced recovery after surgery group. Minimally invasive surgery was more commonly performed in the enhanced recovery after surgery group. Both bleeding with sequelae ( p < 0.0001) and bleeding without sequelae ( p = 0.0004) were significantly more common in the enhanced recovery after surgery group compared to the nonenhanced recovery after surgery group. In addition, a significantly larger hematocrit decline after the operation was noted in the enhanced recovery after surgery group ( p < 0.0001). However, both the need for transfusion and intervention for bleeding did not significantly differ between patient groups. Factors associated with bleeding were the use of an enhanced recovery after surgery protocol (OR 2.96; 95% CI, 1.57-5.58; p < 0.001) and performing a small to large bowel anastomosis (OR 2.68; 95% CI, 1.49-4.81; p < 0.001). Retrospective observational design and inability to determine which component of the enhanced recovery after surgery protocol increased the risk of bleeding. Use of an enhanced recovery after surgery protocol in patients undergoing colorectal surgery with an anastomosis is associated with an increased incidence of bleeding without significant difference in the need for transfusion or intervention. See Video Abstract . ANTECEDENTES:Los protocolos de recuperación mejorada después de la cirugía (ERAS) son vías de atención perioperatoria multimodal que han demostrado mejorar las complicaciones posoperatorias y disminuir la duración de la estancia después de la cirugía. Un componente crítico de un protocolo ERAS es el uso de analgesia multimodal no opiácea mediante fármacos antiinflamatorios no esteroideos e inhibidores de la COX-2.OBJETIVO:Comparar la incidencia de sangrado gastrointestinal posoperatorio entre pacientes tratados con y sin un protocolo ERAS.DISEÑO:Revisión retrospectiva de un registro colorrectal prospectivo mantenido.ESCENARIO:Centro de referencia colorrectal grande.PACIENTES:Cirugía colorrectal electiva preoperatoria que requiere una anastomosis.INTERVENCIÓN:El protocolo ERAS estandarizado incluyó celecoxib y ketorolaco.RESULTADO PRINCIPAL:Los resultados posoperatorios incluyeron sangrado (+/- secuelas), reducción del hematocrito después de la operación, intervención para el sangrado (transfusión, endoscopia o cirugía), duración de la estancia hospitalaria y reingreso hospitalario.RESULTADOS:El grupo ERAS (n = 630) y los grupos no ERAS (n = 739) fueron comparables en las características clínicas iniciales excepto por la indicación quirúrgica, con más enfermedad inflamatoria intestinal y menos enfermedad maligna en el grupo ERAS (Tabla 1). La cirugía mínimamente invasiva se realizó con mayor frecuencia en el grupo ERAS. Tanto el sangrado con secuelas ( p < 0,0001) como el sangrado sin secuelas ( p = 0,0004) fueron significativamente más comunes en el grupo ERAS en comparación con el grupo no ERAS. Además, se observó una disminución significativamente mayor del hematocrito después de la operación en el grupo ERAS ( p < 0,0001). Sin embargo, tanto la necesidad de transfusión como la intervención por sangrado no difirieron significativamente entre los grupos de pacientes. Los factores asociados con el sangrado fueron el uso de un protocolo ERAS (OR=2,96; IC del 95% 1,57-5,58; p < 0,001) y la realización de una anastomosis de intestino delgado a grueso (OR= 2,68; IC del 95% 1,49-4,81; p < 0,001).LIMITACIÓN:Diseño observacional retrospectivo e imposibilidad de determinar qué componente del protocolo ERAS causó el sangrado.CONCLUSIÓN:El uso de un protocolo ERAS en pacientes sometidos a cirugía colorrectal con anastomosis se asocia con una mayor incidencia de sangrado sin diferencia significativa en la necesidad de transfusión o intervención. (Traducción-Dr Yolanda Colorado ).

Background: Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique.&#x0D; Objectives: The purpose of the present study was to compare minimal access laparoscopic mesh techniques with open techniques in hernioplasty.&#x0D; Methodology: This pragmatic randomized control trial was conducted in the Department of Surgery at Shaheed Suhrawardy Medical College &amp; Hospital, Dhaka from January 2014 to December 2015 for a period of two years. Patients at any age with both sexes who were presented with inguinal hernia were selected as study population. These patients were divided into two group designated as group A and group B. In group A inguinal hernia repair was performed by laparoscopic technique and in group B open technique was used to repair the inguinal hernia. The comparison was done between open and laparoscopic technique of inguinal hernia repair in terms of duration of operation, per-operative complication, immediate post-operative pain, numbness, duration of hospital stay and time of return to normal activities. Follow up was done from 6 months to 2 years.&#x0D; Results: A total number of 200 patients were recruited for repairing of inguinal hernia. Duration of operation was longer initially in the laparoscopic groups (Laparoscopic approach 90 min vs. Lichtenstein approach 60 min). Post-operative pain was another important outcome to consider when choosing between laparoscopic and open repair of inguinal hernia. Laparoscopic repair had been associated with less post-operative pain than open repair. Operative complications were uncommon for both methods. Length of hospital stay was little shorter in laparoscopic group (laparoscopic 1-2 days vs. open technique 3-4 days); however, return to usual activity was earlier for laparoscopic groups (7 days) where open group: 20-30 days. The data available showed less persisting pain (Overall 8/80 versus 12/100) and less persisting numbness (Overall 3/80 versus 7/100) in the laparoscopic groups.&#x0D; Conclusions: In conclusion, minimal access laparoscopic mesh technique is better than open techniques in inguinal hernia repair.&#x0D; Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 75-78

BackgroundAdvantages of robotic technique over laparoscopic technique in rectal tumor surgery have yet to be proven. Large multicenter, register-based cohort studies within an optimized perioperative care protocol are lacking. The aim of this retrospective cohort study was to compare short-term outcomes in robotic, laparoscopic and open rectal tumor resections, while also determining compliance to the enhanced recovery after surgery (ERAS)®Society Guidelines.MethodsAll patients scheduled for rectal tumor resection and consecutively recorded in the Swedish part of the international ERAS® Interactive Audit System between January 1, 2010 to February 27, 2020, were included (N = 3125). Primary outcomes were postoperative complications and length of stay (LOS) and secondary outcomes compliance to the ERAS protocol, conversion to open surgery, symptoms delaying discharge and reoperations. Uni- and multivariate comparisons were used.ResultsRobotic surgery (N = 827) had a similar rate of postoperative complications (Clavien–Dindo grades 1–5), 35.9% compared to open surgery (N = 1429) 40.9% (OR 1.15, 95% CI (0.93, 1.41)) and laparoscopic surgery (N = 869) 31.2% (OR 0.88, 95% CI (0.71, 1.08)). LOS was longer in the open group, median 9 days (IRR 1.35, 95% CI (1.27, 1.44)) and laparoscopic group, 7 days (IRR 1.14, 95% CI (1.07, 1.21)) compared to the robotic group, 6 days. Pre- and intraoperative compliance to the ERAS protocol were similar between groups.ConclusionsIn this multicenter cohort study, robotic surgery was associated with shorter LOS compared to both laparoscopic and open surgery and had lower conversion rates vs laparoscopic surgery. The rate of complications was similar between groups.

Background: Appendectomy is most common surgical procedure done for treatment of acute appendicitis. Both laparoscopic and open techniques are used for its removal. The aim of this study is to compare the outcome of laparoscopic appendectomy with open appendectomy. Materials and Methods: A retrospective study was conducted in Nobel Medical College And Teaching Hospital, Biratnagar, Nepal from April 2019 to February 2021.Total 90 patients were enrolled in the study of which 44 in laparoscopic appendectomy group and 46 in open appendectomy group. These two groups were compared for demographic profiles, operative time, postoperative pain, length of hospital stay and surgical site infections. Results: Ninety patients underwent appendectomy of which 44 were in Laparoscopic group and 46 in Open group with similar demographic profiles. The mean operative time in Laparoscopic group was 42.95±2.46 minutes where as in Open group it was 35.25±1.87 minutes [p&lt;0.001].The mean postoperative pain at 8 hours in Laparoscopic group was 7.77±1.03 and in Open group 8.45±1.16 [p=0.002], at day one Laparoscopic group 5.01±0.88 and in Open group 5.80±0.99 [p&lt;0.001],at day two Laparoscopic group 3.54 ±1.19 and in Open group 4.26±0.89[p&lt;0.001]. Mean duration of hospital stay in Laparoscopic group was 2.02±0.26 and Open group was 2.52 ±0.54[p&lt;0.001]. Surgical site infections was noted 1(2.27%) in Laparoscopic group and 6(13.04%) in Open group[p=0.029]. Conclusion: Laparoscopic appendectomy offers less postoperative pain, shorter hospital stay, less surgical site infections but prolonged operative time compared to open appendectomy.

Enhanced Recovery After Lung Resection Surgery: Knowing What We Can Do… and Doing It

The Effect of Preoperative Carbohydrate Intake on Length of Stay and Postoperative Recovery Following Laparoscopic Living Donor Nephrectomy

This meta-analysis aims to compare enhanced recovery after surgery (ERAS) vs. standard perioperative practice in the management of living kidney donors. Primary endpoints included mortality, complications, length of stay (LOS) and quality of life after living donor nephrectomy. Medline, Embase, Scopus, Cochrane and Web of Science databases were searched. In total, 3029 records were identified. We then screened 114 full texts. Finally, 11 studies were included in the systematic review corresponding to 813 living donors. Of these, four randomized controlled trials were included in the meta-analysis. ERAS resulted in shorter LOS (95CI: −1.144, −0.078, I2 = 87.622%) and lower incidence of post-operative complications (95CI: 0.158, 0.582, I2 = 0%). This referred to Clavien–Dindo I-II complications (95CI: 0.158, 0.582, I2 = 0%). There was no difference in Clavien–Dindo III-V complications (95CI: 0.061,16.173, I2 = 0%). ERAS donors consumed decreased amounts of narcotics during their hospital stay (95CI: −27.694, −8.605, I2 = 0%). They had less bodily pain (95CI: 6.735, 17.07, I2 = 0%) and improved emotional status (95CI: 6.593,13.319, I2 = 75.682%) one month postoperatively. ERAS protocols incorporating multimodal pain control interventions resulted in a mean reduction of 1 day in donors’ LOS (95CI: −1.374, −0.763, I2 = 0%). Our results suggest that ERAS protocols result in reduced perioperative morbidity, shorter length of hospital stay and improved quality of life after living donor nephrectomy.

Objective: To investigate the long-term outcome of open and laparoscopic Palomovaricocelectomy in terms of complications. Methods: Data was obtained prospectively about clinical features, complications, recurrence during the two-year period. Statistical analysis was done in order to compare the long-term outcome for the procedures. Results: 72 patients fulfilled the inclusion criteria with a mean follow up time of 16.25 months ± 4.99 SD. Out of these 42 (58.3%) were treated with the open technique while 30 (41.7%) with laparoscopic technique. Overall mean age was 23.82 years ± 4.86 SD with a mean duration of symptoms 11.06 months ± 5.59 SD. 72.4% of complications were encountered within the open Palomo technique group while 27.6% of complications occurred in the laparoscopic group. Similarly, 62.5% of the total recurrent cases occurred in the open group while 37.5% of recurrent cases occurred in the laparoscopic group. Median overall complications rate for open technique (mean rank = 40.00) and laparoscopic technique (mean rank = 31.60) were statistically significantly different, U = 483, z = -1.976, p = 0.048. The distribution of recurrence rates across the two treatment groups is also not significantly different, U = 618.00, z = -0.252, p = 0.801. On the other hand, the distribution of the varicocele grade was not statistically significantly different across the treatment groups, U = 582, z = -0.604, p = 0.546. Conclusions: Laparoscopic and open Palomo techniques for varicocelectomy have comparable outcome in terms of recurrence rates. Overall incidence of complications is higher in the open group.

To study the effectiveness of enhanced recovery after surgery (ERAS) protocol versus traditional perioperative management in patients with hepatopancreatobiliary tumors undergoing pancreatoduodenectomy. The study included 111 patients who have undergone pancreatoduodenectomy between January 2014 and December 2019. Patients were divided into 2 groups: perioperative ERAS protocol (85 patients) and traditional treatment (26 patients). Postoperative complications, length of hospital-stay and incidence of readmissions were analyzed. Mean length of hospital-stay for ERAS protocol was 13.4±7.6 days, conventional management - 16.5±7.5 days (p=0.004). Postoperative 30-day mortality was 8.24 and 7.7% in both groups, respectively (p=1.0). Intraoperative blood loss was significantly less in the ERAS group (248.24±214.0 vs. 321.15±155.0 ml, p=0.004). Overall incidence of postoperative complications was 56.5% and 65.4%, respectively (p=0.420). However, incidence of Clavien-Dindo grade IV complications was significantly higher in case of traditional treatment (19.2 vs. 4.7%, p=0.015). Readmission rate within 30 days was slightly less in the ERAS group (6.4 vs. 20.8%, p=0.052). Enhanced recovery after surgery protocol is safe, reduces the number of postoperative complications, length of hospital-stay and rate of readmissions.