Enhanced Recovery Program Research Articles

773 The Impact of Introducing an Enhanced Recovery Nurse Practitioner on Colorectal ERP Protocol Compliance and Surgical Outcome: A Single-Unit Experience

Abstract Introduction The enhanced recovery programme (ERP) is a validated perioperative care plan that has consistently shown to reduce morbidity and improve patient outcomes. Our trust introduced ERP for major elective colorectal procedures in 2007. However, it had been noted that compliance to protocol was variable. This audit was conducted to see if introduction of an enhanced recovery nurse (ERN) improved compliance. Method This was a single-centre, retrospective, closed-loop audit; each cycle consists of resectional cases over a 1-year period. Perioperative data were collected from preoperative assessment documents, anaesthetic charts, operation notes and post-operative patient records. Compliance to 20elements of the agreed ERP protocol and length of stay (LOS) were assessed. First-cycle results were presented locally, leading to protocol revision and introduction of a dedicated ERN. Two years following ERN introduction, data were re-audited and compliance assessed. Statistical analyses were performed using Chi-squared test or independent t-test as appropriate. Results Among 101 procedures analysed in the first-cycle, compliance to ERP elements ranged between 30-95%. Following intervention, among 113 cases, compliance improved to 46-99%. Statistically significant improvements were observed in post-operative ERP elements. Compliance to early cessation of intravenous fluids increased from 44% to 61% (p = 0.02), and early urinary catheter removal increased two-fold, from 30% to 62% (p < 0.01). Patients resumed light diet earlier and mobilised out of bed sooner. LOS improved from median of 7(1-48) to 6(2-50) days (p = 0.03). Conclusions This study demonstrates that the introduction of a dedicated ERN is associated with significantly improved protocol compliance and reduced LOS following major colorectal resection.

1132 How Much Are Junior Doctors Aware and Knowledgeable of Colorectal Enhanced Recovery Program? A General District Hospital Audit

Abstract Aim Aim of the study is assessment of awareness and knowledge of colorectal Enhanced Recovery Program (ERP) of newly joined junior doctors at a general district hospital. ERP is an essential evidence-based element of surgical colorectal patients’ management during preoperative, operative, and postoperative periods. Junior doctors play an integral part in patients’ management. Local hospital guidelines require 100 % awareness and knowledge of ERP among surgical team members. Method A questionnaire of 15 points for assessment of awareness (1 point) and knowledge of Colorectal ERP (14 points) among 8 newly joined junior doctors (Senior House Officers, Foundation year 2 and Foundation year 1) was developed in our surgical department in August 2020. Results The responses showed that average score of doctors’ knowledge of ERP was (52.9 %). Two doctors (25%) scored 9 out of 14 (9 /14), two (25 %) scored 8/14, one (12.5 %) scored 7.25 /14, one (12.5 %) scored 7/14, one (12.5%) scored 6/14, one (12.5%) scored 5 /14. Regarding awareness of ERP, 5/8 doctors were aware of ERP (62.5 %). Conclusions The study showed presence of a variable average level of awareness and knowledge of ERP among newly joined junior doctors. This was less than local guidelines target (100%). The study recommends education (power point presentation) for improving awareness and knowledge of ERP among newly joined junior doctors. This is to be followed by re-auditing and closing the audit loop.

1144 How Much Does Colorectal Enhanced Recovery Program Education Affect Knowledge of Newly Joined Junior Doctors? A General District Hospital Re-Audit

Abstract Aim Aim of the study is closing the audit loop on knowledge of colorectal Enhanced Recovery Program (ERP) among newly joined junior doctors in a general district hospital. Original audit showed shortage of awareness and knowledge among newly joined junior doctors. The recommendation was educating them regarding ERP and re-auditing. Method Education through a 30-minute power point presentation, on colorectal ERP, was done among newly joined junior doctors. This was followed by a 12-point questionnaire for testing the knowledge of colorectal ERP protocol among 5 newly joined junior doctors (Senior House Officers, Foundation year 2 and Foundation year 1) in our surgical department in August 2020. Results The responses showed an increase in doctors’ knowledge to 90 % (re-audit) from 52.9% (original audit). An increase of about 40% in their knowledge. The average score of their knowledge was 10.8/12 (90 %). One doctor (20 %) scored 12 out of 12 (12/12), two (40 %) scored 11/12 and two (40 %) scored 10/12. Conclusions The study showed that education of newly joined junior doctors resulted in a substantial improvement in their level of knowledge of colorectal ERP, almost up to the local hospital guidelines target (100 %). The study recommends this education to be an integral part of their induction program not only locally but also nationwide. It highlights the impact of education on colorectal ERP implementation.

1245 Enhanced Recovery Program in Colorectal Surgery at Basildon And Thurrock University Hospital

Abstract Introduction Enhanced recovery program (ERP) is an integrated multidisciplinary approach that requires participation and commitment from different member of staff, and the patient. This is an evidence-based protocol designed to standardize medical care, improve outcomes, and lower care costs. The aim of this study is to observe how ERP protocol is followed in our institution, and to monitor different outcomes. Data was compared to NICE guideline. Method We reviewed all patients who underwent elective colorectal resection for cancer between June 2018 and May 2019. data was collected retrospectively from patient electronic case notes. We monitored compliance with ERP protocol (NICE), as well as outcomes Results 114 patients were included in our study. We noted that just 35% of patients had intraoperative nasogastric tube. Antibiotics: 74.56%, Catheter 98.24%, PCA 79.82%, Spinal anaesthesia 52.63%, Drain 38.59%. In the post op period, patients were mobilized at 1.89 day (1.27) [mean (SD)], NGT removal: 1.81 day (2.31) Refeeding: 1.36 day (1.01). It has been proven that patients with inadequate perioperative analgesia are more prone to develop ileus, to have a prolonged hospital stay, and have an overall higher mortality (p0.001) Conclusions It seems that there is a room for improvement especially in analgesia and prophylactic antibiotics. Following ERP protocols improves overall outcomes.

Enhanced Recovery Program: Does Preoperative Education Reduces Length of Hospital Stay in Primary Hip and Knee Arthroplasty?

IntroductionTotal knee and hip arthroplasty significantly improve the quality of life in people suffering from end-stage hip and knee arthritides. Enhanced recovery programs have shown improved outcomes following elective arthroplasty by decreasing patients’ anxiety, postoperative pain and reducing the length of hospital stay (LOS). The aim of our study is to evaluate the impact of preoperative education programs on LOS in patients undergoing hip and knee arthroplasty.MethodsRetrospective data was collected from a consecutive series of 520 patients’ charts and the Irish National Orthopaedic Register (INOR) for those who underwent hip or knee arthroplasty from January 1, 2018 to December 31, 2018 in our hospital. The LOS study compared 226 patients in the Educational Group (EG) who attended the Hip & Knee School (Preoperative Education Class) with 294 patients in the Conventional Group (CG) who did not attend the hip and knee educational program. ResultsWe identified that LOS decreased to 5.2 days in EG from 5.5 days in CG (p-value equals 0.26, statistically insignificant, t = 1.1093, df = 518), with a mean difference of only 0.3 days (95% CI). ConclusionPreoperative education does not reduce the LOS in primary hip and knee arthroplasty.

Клиническое значение влияния инфузионной терапии по рестриктивному типу на восстановление моторики желудочно-кишечного тракта после панкреатодуоденальной резекции

Актуальность. Современные достижения в хирургических и анестезиологических технологиях позволили снизить уровень летальности после панкреатодуоденальной резекции (ПДР) до 3 %, однако послеоперационные осложнения при данной патологии достигают 29,5–70 %. Поэтому вопрос поиска и избежания факторов, вызывающих возникновение осложнений после ПДР, является одним из важнейших в развитии современной хирургической панкреатологии. Материалы и методы. Для оценки эффективности схем периоперационного лечения было проведено проспективно-ретроспективное исследование результатов ПДР 78 больных с доброкачественной и злокачественной патологией билиопанкреатодуоденальной зоны за период с 2003 по 2017 г. С 2015 года при выполнении операции начато применение программы ускоренного восстановления (ПУВ). С целью сравнительного анализа больные были разделены на две группы: в I группу (основная) включено 39 пациентов за период с января 2015 по декабрь 2017 г., периоперационное ведение которых проводили в соответствии с ПУВ, во II группу (группа сравнения) ретроспективно отобраны 39 пациентов за период с января 2003 по октябрь 2014 г., периоперационное лечение которых проводилось по традиционному методу. Изучали объем интраоперационной инфузионной терапии, сроки восстановления моторики желудочно-кишечного тракта (ЖКТ) и частоту развития гастростаза. Результаты. Объем применяемых растворов при интраоперационной инфузионной терапии был значительно ниже в первой группе (2100 мл, 95% CI: [1988; 2300] против 3300 мл, 95% CI: [3100; 3500]; p < 0,001). Пациенты I группы вернулись к обычной диете быстрее, чем пациенты ІІ группы (1,00, 95% CI: [1,00; 1,00] против 6,00, 95% CI: [6,00; 7,00]; p < 0,001). При статистическом анализе по данным ROC-кривой была выявлена взаимосвязь между объемом интраоперационной инфузионной терапии и сроком удаления назогастрального зонда и восстановлением перорального питания в послеоперационном периоде. Выводы. Применение рестриктивного типа инфузионной терапии в концепции ПУВ достоверно сокращает сроки восстановления моторики ЖКТ, уменьшая частоту гастростаза у пациентов после ПДР. Обнаружилось, что статистически достоверным фактором влияния на возможность проведения раннего перорального питания является объем интраоперационной инфузии у пациентов после ПДР.

Introduction of an enhanced recovery programme for total shoulder arthroplasty: report of a novel pathway

BackgroundEnhanced recovery (ER) programmes are well established in hip and knee arthroplasty, but are not yet commonplace for total shoulder arthroplasty (TSA). This study analyses the effect of implementing an...

Enhanced Recovery After Urogynecologic Surgery: A Survey of Patient Experience.

The aim of this study was to identify which aspects/components of the enhanced recovery program (ERP) were associated with a positive patient surgical experience for patients undergoing urogynecologic surgery. A total of 198 patients who underwent pelvic reconstructive surgery requiring hospital admission were invited to complete questionnaires modeled after the validated Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey patient experience survey. Patients were asked about 3 phases of ERP interventions: (1) before surgery (patient education, carbohydrate loading), (2) during the hospital stay (pain control, nausea, early ambulation), and (3) after discharge (return of bladder and bowel function). One hundred patients completed the survey (51% response rate). Greater than 90% of patients rated their overall surgical experience favorably (≥8 on 1-10 scale) regardless of age (P = 0.98), race (P = 0.26), education level (P = 0.12), perception of overall health (P = 0.17), or number of prior surgical procedures (P = 0.86). Ninety-two percent of patients reported that preoperative teaching about surgery was "very helpful," and specifically 90% reported that the ERP educational handbook was useful. Patients who reported a poor perception of their overall mental health were more likely to rate their surgical experience less favorably (<8 on 1-10 scale; P = 0.01), as were patients who left the hospital with a Foley catheter (P = 0.03). Greater than 90% of women surveyed who rated undergoing inpatient pelvic reconstructive surgery positively perceived their surgical experience within the ERP. The majority of patients who had a positive perception of the perioperative experience found the preoperative patient education useful.

Assessment of Body Composition as an Indicator of Early Peripheral Parenteral Nutrition Therapy in Patients Undergoing Colorectal Cancer Surgery in an Enhanced Recovery Program.

Background: A poor body composition (BC) has been identified as a risk factor for patients with colorectal cancer (CRC). This study was performed to assess the effect of early peripheral parenteral nutrition (PPN) on BC in patients undergoing CCR surgery within an enhanced recovery program. Methods: Patients with normal nutritional status were prospectively included between October 2016 and September 2019, randomized into two groups (PPN with periOlimel N4-E versus conventional fluid therapy) and subsequently classified according to their preoperative CT scan into high- or low-risk BC groups. Postoperative complications and length of hospital stay (LOS) were assessed. Results: Of the 156 patients analyzed, 88 patients (56.4%) were classified as having high-risk BC according to CT measurements. PPN led to a 15.4% reduction in postoperative complications in high-risk vs. 1.7% in low-risk BC patients. In the multivariate analysis, high-risk BC was related to an OR (95% CI) of 2 (p = 0.044) of presenting complications and of 1.9 (p = 0.066) for major complications, and was associated with an increase in LOS of 3.6 days (p = 0.039). Conclusions: The measurement of patients’ BC can allow for the identification of target patients where PPN has been proven to be an effective tool to improve postoperative outcomes.

Oncologic Surgical Care Using an Enhanced Recovery Approach

Enhanced recovery programs are multimodal, evidence-based perioperative programs designed to improve a patient's functional recovery after surgery. Enhanced recovery programs promote standardized, multidisciplinary care throughout the perioperative course to improve patient outcomes, rather than focusing on surgical technique. It is important for nurses working in acute and critical care to be aware of the paradigm shift created by the trend toward the enhanced recovery approach. By learning more about facets of the approach, the nurse will be better prepared to adopt whatever aspects of enhanced recovery their institution implements for the surgical oncology population. An overview is provided of the potential components of enhanced recovery.

Standardization of Laparoscopic Intracorporeal Ileal Conduit Urinary Diversion: Step-by-Step Technique

Abstract Introduction: Radical cystectomy (RC) is a complex procedure with a non-negligible morbidity. Decrease in complications may be achieved by implementation of enhanced recovery programs, but...

Study of Visual and Aural Memory Characteristics Under Functional State Changing

The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit.Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs.There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from $31,926 in 2008 to $22,044 in 2013 (p < 0.01).Sequential implementation of the ERP and SSIB provided incremental improvements in CRS outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care.

Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey

BackgroundEnhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP).MethodsA retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure.Results1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together.ConclusionERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

Effect of posture on pulmonary function and oxygenation after fast-tracking video-assisted thoracoscopic surgery (VATS) lobectomy: a prospective pilot study

BackgroundMinimally invasive surgery combined with enhanced recovery programmes has improved outcomes after lung cancer surgery and where early mobilisation may be an important factor. However, little is known about pulmonary function and oxygenation during mobilisation after video-assisted pulmonary lobectomy. The aim of this prospective pilot cohort study was to explore the effect of postural changes (from supine to sitting to standing) on pulmonary function and oxygen saturation in a well-defined enhanced recovery programmes setting after video-assisted thoracoscopic surgery lobectomy.MethodsA total of 24 patients were evaluated daily for postoperative pain score, pulmonary function (forced expiratory volume 1 s) and oxygen saturation in supine, sitting and standing position from 6 h after surgery to 6 h after chest drain removal.ResultsMobilisation from supine to standing position showed a significant 7.9% increase (p = 0.04) in forced expiratory volume in 1 s percentage and oxygen saturation about 1.8% (p< 0.001) without increasing pain (p = 0.809).ConclusionsEarly mobilisation should be encouraged to enhance recovery after video-assisted thoracoscopic surgery lobectomy by increasing lung function and oxygen delivery.Trial registration• Name of the registry: clinicaltrials.gov• Trial registration number: NCT04508270• Date of registration: August 11, 2020

Enhanced recovery program in liver surgery

Since the development of fast-track programs in colorectal surgery with promising results, many centers started with these programs, and improved them. These programs were applied to different organs with the same results observed in colorectal surgery. Liver resections were not excluded from enhanced recovery programs, with a significant reduction in length of hospital stay and costs. Adequate patient information and commitment, multimodal analgesia, fluid therapy and early oral intake are the most important items of these programs.

Ambulatory surgery for cancer patients: current controversies and concerns.

This review aims to describe the main concerns and controversies of ambulatory surgery in cancer patients while providing an overview of ambulatory cancer anaesthesia. Cancer patients can undergo a variety of ambulatory surgeries. The introduction of robotic approach and the implementation of enhanced recovery programmes have allowed patients to avoid hospital admissions after more complex or invasive surgeries. In this context, the anaesthesiologist plays a key role in ensuring that the ambulatory surgical centre or the hospital-based ambulatory department is equipped for the perioperative challenges of the cancer population. Cancer patients tend to be older and with more comorbidities than the general population. In addition, these individuals may suffer from chronic conditions solely because of the cancer itself, or the treatment. Consequently, frailty is not uncommon and should be screened on a routine basis. Regional analgesia plays a key role in the provision of opioid-sparing multimodal analgesia. Neither regional anaesthesia or general anaesthesia have proven to affect the long-term oncological outcomes of cancer patients undergoing ambulatory surgery. In addition, there is insufficient evidence to suggest the use of total intravenous anaesthesia or inhalational anaesthesia over the other to decrease cancer recurrence.

Improved Recovery Protocols in Cardiac Surgery: A Systematic Review and Meta-Analysis of Observational and Quasi-Experimental Studies.

Improved recovery protocols were implemented in surgical specialties over the last decade, which decreased anesthetic and surgical stress and the incidence of perioperative complications. However, these recovery protocols were introduced more slowly for cardiac surgeries. The most frequent complications in cardiac surgery are related to patient clinical status and the characteristics of the surgical procedures involved, which are becoming more varied and complex every day. The first version of the enhanced recovery program for cardiac surgery was published in 2019, but its recommendations were based on only a few studies, and scant research has evaluated its implementation. Randomized and controlled clinical trials for these protocols are scarce, so research that summarizes the results of studies with other methodological designs are useful in demonstrating their benefits in cardiovascular surgery services in Cuba and in other limited-resource settings. Estimate the effectiveness of improved recovery protocols in the perioperative evolution of patients undergoing cardiac surgery. We performed a systematic review and meta-analysis according to the guidelines of manual 5.1.0 for reviews of the Cochrane library. We included observational and quasi-experimental studies published from January 2015 through May 2020 that compared enhanced recovery protocols with conventional treatments in patients older than 18 years, and used a quality score to evaluate them. We used the following sources: the Cochrane Library, PubMed, LILACS, SciELO, EBSCO, Google Scholar, Web of Science, Clinical Key, ResearchGate and HINARI. The following keywords were used for the database searches in English: ERAS, protocols and cardiac surgery, enhanced recovery after cardiac surgery, ERACS, clinical pathway recovery and cardiac surgery, perioperative care and cardiac surgery. We used the following search terms for databases in Spanish: protocolos de recuperación precoz and cirugía cardiaca, protocolos de recuperación mejorada and cirugía cardiaca, cuidados perioperatorios and cirugía cardiaca, programas de recuperación precoz and cirugía cardiovascular. Methodological quality of included investigations was evaluated using the surgical research methodology scale. Meta-analyses were performed for perioperative complications, intensive care unit and hospital stays, and hospital readmission within 30 days of surgery. We calculated effect sizes of the interventions and the corresponding 95% confidence intervals. We used mean differences and confidence intervals for continuous variables, and for qualitative variables we calculated relative risk (RR). Random effects analysis was used. Heterogeneity of the studies was assessed using the Q statistic and the I2 statistic. We selected 15 studies (a total of 5059 patients: study group, n = 1706; control group, n = 3353). The average quality score for the 15 articles included was 18.9 (out of a maximum of 36 according to the scale) and 66.6% had a score =18. With improved recovery protocols in cardiac surgery, the incidence of perioperative complications decreased (RR = 0.73; 95% CI 0.52-0.98) as did hospital readmission within 30 days after surgery (RR = 0.51; 95% CI 95% CI: 0.31-0.86). Differences in extubation time, hospital stay and length of stay in intensive care units were less marked, but always favored the group in which the enhanced protocols were implemented. Improved recovery protocols in cardiac surgery increase quality of care evidenced by reductions in perioperative complications and decreased incidence of hospital readmission in the month following surgery.

Effect of Early Peripheral Parenteral Nutrition Support in an Enhanced Recovery Program for Colorectal Cancer Surgery: A Randomized Open Trial

Background: Peripheral parenteral nutrition allows repletion of acute nutrient deficiencies and could prevent further nutrition deficits before and after colorectal surgery. A randomized open study was performed to evaluate the effect of perioperative peripheral parenteral nutrition (PPN) support on postoperative morbidity after colorectal cancer surgery within an enhanced recovery program. Methods: Patients were randomized into two groups: peripheral parenteral nutrition (PPN) (with Peri-Olimel N4-E) versus conventional fluid therapy (FT). Ninety-day postoperative complications, laboratory parameters, length of hospital stay, and compliance with the ERAS protocol were assessed. Results: A total of 158 patients were analysed. The overall 90-day complication rate was 38.6% (61 patients), and 24 patients had major complications (Clavien–Dindo III–V) (15.2%). In the multivariate analysis, the intervention (PPN vs. FC) showed a protective effect against postoperative complications (p = 0.0031, OR = 0.2 (CI: 0.08–0.87)). Following ordinal regression, PPN and early oral tolerance showed a protective effect, being less likely to develop complications or to move from minor to major complications. In patients with low compliance to ERAS during the first postoperative day, PPN showed a protective effect, preventing 28% of morbidity. Conclusions: Perioperative peripheral parenteral nutrition (PPN) support with Peri-Olimel N4-E in colorectal cancer surgery associated with early oral intake could reduce postoperative complications.

Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis

BackgroundEnhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery.MethodsERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann–Whitney Fisher’s exact T test or Pearson Chi-square test) was used.ResultsBoth groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (−€2 356), intensive or intermediate care (−€8 629), medication (−€1 196)), physiotherapy (−€611), laboratory (−€1 625)) and blood transfusion (−€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group.ConclusionERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery.

The impact of intensive care unit stay following oesophagectomy for oesophageal cancer on long‐term survival

AbstractAimSurvival in patients with oesophageal cancer is associated with an overall poor 5‐year survival rate. The aim of this study was to determine whether return to theatre, overall and intensive care unit (ICU) length of stay (LOS) impact long‐term survival.MethodsA single‐institution dataset of prospectively collated data from January 2011 to December 2018 were analysed. Survival analysis using multivariable Cox regression analyses were undertaken to determine factors associated with survival.ResultsA total of 190 patients underwent an oesophagectomy, of whom 81.6% (155/190) were male and the median age was 66 years (interquartile range 58‐72 years). The median length of stay was 12 days (interquartile range 10‐15 days). At a mean follow‐up of 36 months, 41.9% (117/279) of the population were deceased. Nodal, N3 staging [hazard ratio (HR) 5.30, 95% confidence interval (CI) 2.92‐9.63] was associated with poorer survival. Prolonged ICU stay of 5 to 7 days (HR 2.26, 95% CI 1.18‐4.33, P = .015), 8 to 10 days (HR 3.96, 95% CI 1.65‐9.50, P = .002) and over 10 days (HR 2.47, 95% CI 1.11‐5.47, P = .027) was also associated with significantly worse survival.ConclusionProlonged ICU stay after oesophagectomy has a negative impact on survival irrespective of the tumour stage. Enhanced recovery programs aimed at fast‐tracking ICU care and early safe patient discharge may improve long‐term survival.