Enhanced Recovery Program Research Articles

Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty.

Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population. A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation. Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09). Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.

Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme.

Background Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated. Method Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified. Results Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome. Conclusions The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.

565 Outcome of Enhanced Recovery Programme in Lower Limb Arthroplasties

Abstract Background Enhanced Recovery Programme(ERP) is structured process of patient education, appropriate analgesia and early mobilisation. ERP was introduced to address, demand for surgical beds and cancellation of orthopaedic procedures. Objectives of this study were to evaluate efficacy and safety of ERP. Method This was prospective study, over three months. Included, all lower limb arthroplasty patients eligible for ERP(all primary arthroplasty patient with lower anaesthetic risk). Pre-medication, intra-operative local anaesthetics infiltration, same day post-operative radiograph, combinations of analgesics, early mobilisation, and discharge back to the usual place of abode. Results 201 patients, mean age was 71 years (42-87), 22 ASA (American Society of Anaesthesia) 1, 147 ASA 2 and 23 ASA 3 patients. Performed 121 total knee replacements and 80 total hip replacements. Average duration of weight bearing was1.04 days. Mean date of discharge was 1.37days (0-5). 8 patients were re-admitted (0.039%), they were, one with surgical site infection, another one for manipulation, 5 patients, suspected deep vein thrombosis (DVT) (all were excluded DVT). There was no failed discharge. Conclusions ERP is very safe and effective way of increasing performance of hip and knee arthroplasties by optimising availability of ring-fencing surgical beds and reducing the hospital stay.

Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program.

In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p=0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to-2%, p=0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p<0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p<0.001). Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.

P23: ENHANCED RECOVERY PROGRAMME – DOES PREOPERATIVE EDUCATION REDUCE LENGTH OF HOSPITAL STAY (LOS) IN PRIMARY HIP &amp; KNEE ARTHROPLASTY

Abstract Introduction Total knee and hip arthroplasty significantly improve quality of life in people suffering from end-stage hip &amp; 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 length of hospital stay in patients undergoing hip &amp; knee arthroplasty. Method Retrospective data was collected from a consecutive series of 520 patients' charts and Irish National Orthopedic Register (INOR) who underwent Hip or Knee arthroplasty from January 1, 2018, to December 31, 2018, in Our Lady Hospital, Navan. The length of stay study compared two hundred and twenty-six patients in the Educational Group (EG) who attended the Hip &amp; Knee School (Preoperative Education Class) with 294 patients in the Conventional Group (CG) who did not attend the hip and knee educational programme. Result We identified that Length of Hospital Stay decreased to 5.2 days in Educational Group from 5.5 days in Conventional Group (P-value equals to 0.26, statistically insignificant, t = 1.1093 df = 518), with a mean difference of only 0.3 days (95% confidence interval). Conclusion Preoperative education does not reduce the length of hospital stay in primary hip &amp; knee arthroplasty. Take-home message Preoperative education has no role in reducing hospital stay in Arthroplasty patients.

P28: LAPAROSCOPIC VERSUS ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK IN LAPAROSCOPIC COLORECTAL SURGERY - A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Introduction A multimodal approach to peri-operative analgesia represents a cornerstone of enhanced recovery programmes in minimally invasive colorectal surgery. Transversus abdominis plane (TAP) block is an emerging anaesthetic technique that may reduce postoperative opiod analgesic requirements. It can be performed laparoscopically or percutaneously. We performed a systematic review and meta-analysis to compare the effectiveness of laparoscopic versus ultrasound-guided TAP block in laparoscopic colorectal surgery. Method PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until November 2019. All studies that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in laparoscopic colorectal resections were included. The primary outcome measure was narcotic consumption at 24 hours postoperatively, while secondary outcomes included pain scores, operative time, postoperative nausea and vomitting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. Result Three randomised controlled trials and one retrospective study were included capturing 309 patients. On random effects analysis, there were no significant differences in narcotic consumption between LTB and UTB (Mean difference -8.12 mg, 95% CI=-22.13 to 5.89, p=0.26). LTB was associated with significantly lower pain scores (Mean difference -0.49, 95% CI=-0.96 to -0.02, p=0.04). There were no differences in operative time (Mean difference -6.67 mins, 95% CI=-29.4 to 16.06, p=0.57), PONV (OR=0.97, 95% CI=0.36 to 2.65, p=0.96) or complication (OR=1.30, 95% CI=0.64 to 2.64, p=0.47) rates. Conclusion LTB is associated with significantly less pain at 24 hours postoperatively but similar narcotic usage, PONV, operative time and complication rates, compared to UTB. Take-home message Laparoscopic transversus abdominis plane block is shown to leave patients with less pain at 24 hours post-op compared to ultrasound guided methods in colorectal patients.

O68: REDUCING VENOUS CONGESTION FOLLOWING LOWER LIMB RECONSTRUCTION WITH ISOMETRIC CALF EXERCISES: A PROSPECTIVE CLINICAL STUDY

Abstract Introduction Early post-operative dependency aids healing following lower limb reconstruction although increases venostasis and reduces perfusion in the acute setting. The commonest cause of lower limb flap failure is venous congestion and external compression with stockings and pneumatic devices is contraindicated. The aim of this clinical study was to determine whether venous congestion could be reduced through patient-led isometric contractions following lower limb reconstruction. Method A single centre prospective clinical study was conducted at St. Marys Hospital, Imperial College NHS Trust. Combined tissue photospectroscopy and laser Doppler (O2C, LEA, Germany) was used to assess superficial oxygen saturation, venous congestion and flow during standardised training regimens. Haemodynamic parameters were collected in an acute post-operative and outpatient rehabilitation cohort. Result In the acute post-operative cohort, isometric contractions failed to improve superficial flow following dependency on the post-operative day (POD) one (-44% ± 8). Isometric contractions improved superficial flow from POD5 (+11% ± 102) although venous congestion remained higher than measurements taken during rest (+32% ± 54). In the outpatient rehabilitation cohort isometric contractions significantly increased superficial flow following dependency (+16% ± 33, p=0.01) at a mean of 14 weeks since discharge. Conclusion This study provides objective physiological evidence of the haemodynamic changes that occur with dependency and isometric contraction following lower limb reconstruction. These physiological changes evolve following extremity reconstruction and it appears that a continued healing effect exists to accommodate progressive changes in flow dynamics. The present findings could be used to inform enhanced recovery programmes following limb reconstruction. Take-home message Simple patient-led calf contractions reduce venous congestion and improve cutaneous flow following lower extremity reconstruction.

Mobilization after joint arthroplasty surgery: who benefits from standing within 12 hours?

Early mobilization following joint arthroplasty surgery has been shown to be beneficial for patients, but it is unclear whether it is associated with a shorter length of stay (LOS) for both hip and knee arthroplasty (KA) patients. We undertook a retrospective observational study, reviewing the case notes of 386 patients admitted to an enhanced recovery programme for total hip (THA) or total/unicompartmental KA. We evaluated the influence of early mobilization on LOS, adjusting for possible confounders, stratifying by surgery type. THA patients first mobilized within 12 h of returning to the acute orthopaedic ward following surgery had a significantly shorter mean LOS (mean=3.6, standard deviation=1.1) than THA patients who first mobilized 12 or more hours (mean=4.1, standard deviation=1.2), P=0.004. There was no statistical significant difference in the mean LOS between the KA patients mobilized earlier or later. Early mobilization as part of an enhanced recovery programme was associated with decreased LOS for patients having THA; however, this was not the case for KA patients.

Comparison of treatment to improve gastrointestinal functions after colorectal surgery within enhanced recovery programmes: a systematic review and meta-analysis

Despite a significant improvement with enhanced recovery programmes (ERP), gastro-intestinal (GI) functions that are impaired after colorectal resection and postoperative ileus (POI) remain a significant issue. In the literature, there is little evidence of the distinction between the treatment assessed within or outside ERP. The purpose was to evaluate the efficiency of treatments to reduce POI and improve GI function recovery within ERP. A search was performed in PubMed and Scopus on 20 September 2019. The studies were included if they compared the effect of the administration of a treatment aiming to treat or prevent POI or improve the early functional outcomes of colorectal surgery within an ERP. The main outcome measures were the occurrence of postoperative ileus, time to first flatus and time to first bowel movement. Treatments that were assessed at least three times were included in a meta-analysis. Among the analysed studies, 28 met the eligibility criteria. Six of them focused on chewing-gum and were only randomized controlled trials (RCT) and 8 of them focused on Alvimopan but none of them were RCT. The other measures were assessed in less than 3 studies over RCTs (n = 11) or retrospective studies (n = 2). In the meta-analysis, chewing gum had no significant effect on the endpoints and Alvimopan allowed a significant reduction of the occurrence of POI. Chewing-gum was not effective on GI function recovery in ERP but Alvimopan and the other measures were not sufficiently studies to draw conclusion. Randomised controlled trials are needed.Systematic review registration number CRD42020167339.

Improvement of Outcome by Implementation of Enhanced Recovery Pathway in Gynecologic/ Oncology Surgery

Background: Enhanced recovery programs (ERPs) are evidence-based protocols designed to improve functional rehabilitation after surgery. They lead to improvement in patient outcomes while reducing length of hospital stay. Objective: This study aimed to compare surgical outcomes between women undergoing major gynecologic surgeries before and after implementation of enhanced recovery after surgery (ERAS) protocol. Patients and Methods: This erective observational study was carried out on patients attending to Zagazig University Hospitals for Elective Gynecological Oncologic Surgeries in the period between August 2018 and August 2019. Patients and methods: This study included 54 patients who were presenting for elective gynecological oncologic surgeries. They were classified into 2 groups. Group 1 include 27 patients who were exposed to the ERAS protocol regimen for the pre, intra and postoperative care. Group 2 include 27 patients who were exposed to the conventional care known in the literature. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Results: This study showed that the mean length of hospital stay was 38.29 ± 4.95 hours in group A and 68.44 ± 6.5 hours in group B with significant difference between the two groups. Postoperative complications rate was 7.4% in group A vs 11.1% in-group B with no significant difference between the two groups. Conclusions: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.

Link between postoperative ileus and anastomotic leakage: A structural equation modelling approach

IntroductionPostoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). MethodsThis is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. ResultsAmong the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. ConclusionThe findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Male Patients may be More Vulnerable to Acute Kidney Injury After Colorectal Surgery in an Enhanced Recovery Program: A Propensity Score Matching Analysis.

Although many reports have shown that enhanced recovery after surgery (ERAS) programs improve the perioperative outcomes of patients undergoing colorectal surgery, the prevalence of early acute kidney injury (AKI) after surgery in such patients requires attention. Protective roles of the female sex in terms of chronic kidney disease and progression of ischemic renal injury have been described in many studies. We thus explored whether a sex difference was evident in terms of postoperative AKI in a colorectal ERAS setting. From January 2017 to August 2019, 453 patients underwent laparoscopic colorectal cancer resection in an enhanced recovery program. Of these, 217 female patients were propensity score (PS)-matched with 236 male patients. Then, 215 patients of either sex were compared in terms of postoperative renal function and complications. Among the PS-matched patients, the incidence of AKI was significantly higher in male than female patients (24.2% vs. 9.8%, P < 0.001). Male patients also exhibited a greater reduction in the postoperative estimated glomerular filtration rate, compared with female patients. The male sex was associated with an approximately threefold increase in the risk of AKI. The rate of surgical complications was significantly higher in male than female patients. Caution must be taken to prevent postoperative AKI in patients (particularly males) participating in colorectal ERAS programs. The mechanism underlying the sex difference remains unclear. Additional studies are required to determine whether male patients require perioperative management that differs from that of females, to prevent postoperative AKI.

Obstetrical Patient Engagement and Data Collection: The Value of Technology in Enhanced Recovery Programs

Enhanced recovery at cesarean section refers to a multimodal and multidisciplinary pathway aimed at accelerating patient recovery. The program’s success requires patient engagement throughout the perioperative period, as well as post-discharge, which is made possible with the help of technology. Our institution’s state of the art patient engagement smartphone application provides on-demand patient education and allows for remote monitoring both pre and postoperatively. Further, the application surveys patients regarding preoperative surgical fear, program compliance, opioid risk, amongst other data points, that are collected to an analytics dashboard, which can be viewed pre- and postoperatively. This application is particularly helpful post-discharge when it is more difficult to have continued patient engagement and program assessment. Thus, we argue that technology is essential to the success of an enhanced recovery program and in future research aimed at studying the comprehensive benefit of these programs on maternal recovery and outcomes.

How to reduce failure to rescue after visceral surgery?

Mortality after visceral surgery has decreased owing to progress in surgical techniques, anesthesiology and intensive care. Mortality occurs in 5-10% of patients after major surgery and remains a topic of interest. However, the ratio of mortality after postoperative complications in relation to overall complications varies between hospitals because of failure to rescue at the time of the complication. There are multiple factors that lead to complication-related mortality: they are patient-related, disease-related, but are related, above all, to the timeliness of diagnosis of the complication, the organisational aspects of management in private or public hospitals, hospital volume that corresponds to the centralisation of initial management or to the concept of referral centre in case of complications, to the team spirit, to communication between the health care providers and to the management of the complication itself. Several organisational advances are to be considered, such as the development of shorter hospitalisations and notably ambulatory surgery, as well as enhanced recovery programs. Remote monitoring and the contribution of artificial intelligence must also be evaluated in this context. The reduction of mortality after visceral surgery rests on several tactics: prevention of potentially lethal complications, the all-important reduction of failure to rescue, and risk management before, during and after hospitalisations that are increasingly shorter.

Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion.

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

Enhanced Recovery after Robot-Assisted Partial Nephrectomy for Cancer: Is it Better for Patients to Have a Quick Discharge?

Objectives: The aim of the study was to assess the efficacy and safety of an enhanced recovery program (ERP) after robot-assisted partial nephrectomy (RAPN) for cancer. Methods: It was a monocentric, retrospective, comparative study. An ERP after RAPN was introduced at our institution in 2015 and proposed to all consecutive patients admitted for RAPN. The control group for this study was composed of patients managed immediately before the introduction of the ERP. We collected information on patient characteristics, tumor sizes, ischemia times, biology, hospital length of stays, postoperative (≤30 days) complications, and readmission rates. Group comparisons were made using the Pearson χ² test for qualitative data and the Student t test for quantitative data. Results: Between 2015 and 2017, 112 patients were included in the ERP group. Fifty patients were included in the control group. Ninety patients in the ERP group (80.4%) were discharged at or before postoperative day (POD) 2 versus 10 patients (20%) in the control group (p < 0.001). There was no significant difference between the ERP and control groups for the urinary retention rate (respectively 3.6 vs. 2%; p = 0.593). Resumption of normal bowel function was significantly shorter in the ERP group (94.6% at POD1 vs. 69.6% in the control group, p < 0.001). There were no significant differences for postoperative complications (15.2% in the ERP group vs. 20% in the control group, p = 0.447) or readmissions within 30 days (8.04 vs. 0.2%, p = 0.140). Conclusions: ERP after RAPN seems to reduce postoperative length of stay without increasing postoperative complications or readmissions.

Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic.

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Diagnosis of colorectal and emergency surgical site infections in the era of enhanced recovery: an all-Wales prospective study.

Surgical site infections (SSIs) are associated with increased morbidity, hospital stay and cost. The literature reports that 25% of patients who undergo colorectal surgical procedures develop a SSI. Due to the enhanced recovery programme, patients are being discharged earlier with some SSIs presenting in primary care, making accurate recording of SSIs difficult. The aim of this study was to accurately record the 30-day SSI rate after surgery performed by colorectal surgeons nationally within Wales. During March 2019, a national prospective snapshot study of all patients undergoing elective or emergency colorectal and general surgical procedures under the care of a colorectal consultant at 12 Welsh hospitals was completed. There was a multimodal 30-day follow-up using electronic records, clinic visits and/or telephone calls. Diagnosis of SSI was based on Centers for Disease Control and Prevention diagnostic criteria. Within Wales, of the 545 patients included, 13% developed a SSI within 30days, with SSI rates of 14.3% for elective surgery and 11.7% for emergency surgery. Of these SSIs, 49.3% were diagnosed in primary care, with 28.2% of patients being managed exclusively in the community. There were two peaks of diagnosis at days 5-7 and days 22-28. SSI rates between laparoscopic (8.6%) and open (16.2%) surgeries were significantly different (p=0.028), and there was also a significantly different rate of SSI between procedure groups (p=0.001), with high SSI rates for colon (22%) and rectal (18.9%) surgery compared with general surgical procedures. This first all-Wales prospective study demonstrated an overall SSI rate of 13%. By incorporating accurate primary care follow-up it was found that 49.3% of these SSIs were diagnosed in primary care.

Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial.

BackgroundThe clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics.ObjectiveWe aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection.MethodsThe enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival.ResultsPatients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery.ConclusionsERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.

Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial.

We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program. We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated. Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048). Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.