Perioperative Care Pathways Research Articles

Utilization of a Perioperative Care Pathway for Pediatric Alveolar Bone Grafting: A Quality Improvement Initiative.

To develop, implement, and evaluate a standardized perioperative care pathway for pediatric patients undergoing alveolar bone grafting from the anterior iliac crest. A historical control group of 40 patients was reviewed retrospectively and compared to a prospectively collected treatment group of 40 patients who were treated with the new pathway. Tertiary-level academic pediatric hospital between 2018 and 2021. Pediatric patients with nonsyndromic cleft lip and palate undergoing alveolar bone grafting. A perioperative clinical care pathway was specifically designed for patients undergoing alveolar bone grafting from the anterior iliac crest. The pathway involved standardization of perioperative care, ultrasound-guided regional anesthesia for both surgical sites, and scheduled postoperative analgesia. (1) Length of hospital stay; (2) opioid consumption postoperatively; and (3) volume of oral intake in the first 24 h postoperatively. Data was analyzed via comparison of means (Student's t-test for continuous data and Chi-square test for categorical data) and control chart analysis. Compared to the control group, patients in the treatment group had lower mean length of stay (26.8 vs 37.8 h, p < .001), lower mean morphine consumption postoperatively (8 vs 34 mcg/kg, p = .008), and a higher proportion of patients not requiring any postoperative opioid use (80% vs 50%, p = .005). Implementation of a standardized clinical care pathway for pediatric patients undergoing alveolar bone grafting from the anterior iliac crest is feasible and was associated with significant reductions in postoperative length of stay and postoperative opioid requirements.

Enhanced recovery after surgery (ERAS) a multimodal perioperative care pathway in cesarean deliveries

Enhanced Recovery After Surgery (ERAS) is an evidence based perioperative program applied for early recovery of patients after surgery to reduce the postoperative surgical stress and hasten early physiological and functional recovery. The present study is focused on application of ERAS protocol in the branch of obstetrics following cesarean sections.The primary objective is to compare the efficacy between post-operative recommendations of ERAS protocols and traditional post-operative care in cesarean sections. A total of 300 patients were included in this study from November 2020 to October 2022 from the inpatient department of Obstetrics and Gynaecology of Pradyumna Bal Memorial hospital, KIMS, Bhubaneswar. Out of 300 patients, 150 were in ERAS group and 150 were in control (conventional) group. The median Length of stay (LOS) of ERAS and control group were 3 and 5 days respectively (p&amp;#60;0.01). The median patient satisfaction score on Likert scale was 4 and 3 for ERAS and control group respectively (p&amp;#60;0.01).The application of ERAS in post-operative period after cesarean has showed significant results in decreasing length of stay and better patient satisfaction score.

AHP SO07 - Dietetic Outpatient Service to Patients undergoing Oesophagogastric (OG) Surgery for Cancer

Abstract Background Nutrition is a modifiable risk factor impacting surgical outcomes in OG cancer. Its key role influencing health related quality of life is emerging with improved survivorship. Guidelines depicting optimal timing and type of dietetic intervention for this patient group are unclear. In order to best direct dietetic care, optimise timing of nutritional interventions and understand demand for service it is important to reflect on current provision. This audit aimed to describe the dietetic outpatient service to patients undergoing OG Surgery for cancer in a national centre for treatment of oesophageal cancer. Method A retrospective review of dietetic records and statistics. Patients who underwent oesophagectomy (O), gastrectomy (G) or subtotal gastrectomy (STG) for cancer between May 2022- May 2023 were included. Results 63 patients were included: 38 O, 17 TG, 8 STG. 11 were seen by the dietitian at first visit to OG Clinic (9 O, 1 TG, 1 STG) – 6 had an elective feeding tube (FT) inserted for neoadjuvant treatment (5 O, 1 STG). 83% attended a surgical pre-assessment dietetic appointment (36 O, 14 TG, 2 STG). 86% were reviewed within 1 month post O or TG, 75% post STG. 258 dietetic interventions occurred in the first year post-op (median 3.5, range 0-14). 64% in the first 3 months(m) post op, 16% at 3-6m, 10% at 6-9m, 10% at 9-12m. Conclusion In this high nutritional risk group only 18% are assessed by a dietitian at first visit to UGI MDT clinic. There is a successful pathway for immediate peri-operative dietetic care in patients post O and TG. The pathway for STG is less well established. Dietetic interventions are concentrated in the first 3 months after surgery. There is no established protocol to support longer term nutritional needs into survivorship. To inform practice a measure of patient experience and needs would be useful, to explore best delivery format and access routes to future services.

Implementation of ERAS Protocols: In Theory and Practice.

The enhanced recovery after surgery (ERAS) pathway is a perioperative care pathway intended to facilitate early recovery and minimize hospital stays among patients undergoing major surgery. Critical factors for successful ERAS implementation, which may vary depending on care processes, include a multidisciplinary team, organizational commitment to change, and a real-time system for compliance and outcome audits. As most clinicians and health organizations can attest, incorporating and implementing new evidence-based practice changes almost always involves overcoming systemic challenges and obstacles. The same holds true for ERAS programs. The main barriers to ERAS protocol implementation have been resistance to change, lack of time and resources, and inadequate communication and coordination among departments. According to evidence-based ERAS guidelines, the best way to efficiently implement all recommendations into practice is to discover. Implementation science aims to identify and address care gaps, support change in practice, and enhance healthcare quality. Implementation research should also build a robust and generalizable evidence base to inform implementation practice. Most implementation investigations focus on one of two approaches to achieving change. Implementation can progress through top-down or bottom-up processes depending on factors such as national policies, organizational properties, or the implementation culture of society, especially for health issues. Although the ERAS guidelines are based on evidence-based knowledge, only a limited number of health centers around the world have officially been able to implement them. The purpose of this review is to analyze the implementation of the ERAS pathways in theory and practice in Turkey, considering the absence of an ERAS-qualified center in Turkey.

Consensus-Building Processes for Implementing Perioperative Care Pathways in Common Elective Surgeries: A Systematic Review.

To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries. Systematic review. Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023. Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions. The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions. Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented. Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals. These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. No patient or public contribution. CRD42023413817.

561. COMMONALITY AND VARIATION IN PERIOPERATIVE ESOPHAGEAL CANCER MANAGEMENT IN HIGH VOLUME EUROPEAN CENTERS

Abstract Background Esophageal cancer is a leading cause of cancer related death worldwide. For patients with locally advanced, non-metastatic, esophageal cancer (EC), surgical resection remains an essential pillar. The multitude of surgical options have driven innovation, however, lack standardization and at times high-quality data-driven practices. A surgeon-level in-depth interview and questionnaire was created to understand the perioperative care pathways and intraoperative techniques used by high-volume European EC centres to gain insight into commonality and variation of current practice. Methods Eight (8) expert upper gastrointestinal surgeons were invited to participate in an in-depth interview and questionnaire. The focus included preoperative care pathways for esophageal adenocarcinoma of the distal esophagus/GE junction, technical aspects of esophageal resection (Ivor-Lewis) and postoperative pathways. The involvement of allied health, dedicated research programs, multidisciplinary cancer conference (MCC), follow up protocols and management of T4b EC was also assessed. Results The response rate was 100% (8/8). Majority of respondents indicated a country-level regionalization of EC care. The number of centres performing esophageal resection varied from 4 – &amp;gt;100. Average number of esophagectomies/year ranged from 60-150. All centres presented EC patients at MCC, had dedicated research programs, and participated in National and International EC databases. Chemoradiotherapy was the predominate neoadjuvant treatment for GEJ cancers. Pretreatment clinical staging varied, with all centres having different, but pre-defined, preoperative and postoperative pathways. Intraoperative techniques including conduit preparation, feeding tube use, pyloric intervention, thoracic duct ligation and anastomotic technique varied substantially. There was no consensus regarding follow up or management of T4b EC. Conclusion The perioperative pathways and technical aspects of esophageal resection shared some commonalities however also differed substantially across high-volume EC centres in Europe. Multicenter, pragmatic randomized controlled trials (RCTs) are needed to better delineate which techniques should be included as standard of care, and which should be abandoned.

Enhanced recovery after surgery and intestinal obstruction: A scoping review.

Acute intestinal obstruction is a blockage of the intestine which causes a range of clinical symptoms such as acute and severe abdominal pain, nausea, and obstipation. Intestinal obstruction is a medical emergency and can be life-threatening when left untreated. In cases where treatment involves emergency abdominal surgery, a multimodal perioperative care pathway (enhanced recovery after surgery ERAS) has shown to accelerate patient recovery after surgery, reduce hospital length of stay, and improve overall outcomes. The objective of this scoping review was to identify and synthesize the existing evidence regarding the implementation of ERAS components with a focus on postoperative components in patients undergoing surgery for acute intestinal obstruction. This scoping review followed the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews framework. PubMed-Medline and Embase database were searched. The search identified 1860 studies of which 16 were included in the final analysis. All the studies were quantitative. Eleven studies used 10 or more ERAS interventions (range 10-28). The most common interventions were multimodal systemic analgesia, and the least common were the management of blood glucose and screening tools. This scoping review found that 56% (n=9/16) of the identified studies used 10 or more ERAS interventions out of a possible 35. This review highlighted the need for studies on the ERAS emergency laparotomy guidelines.

Enhanced Recovery after Surgery Protocol (ERAS) versus Standard Protocol for Undergoing Radical Cystectomy in an Egyptian Population

Abstract Background bladder cancer has been one of the commonest cancer. The gold standard for treatment of muscle invasive bladder cancer is radical cystectomy with pelvic lymphadenectomy and associated with considerable morbidity and mortality and healthcare cost. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures. Aim and Objectives The aim of this study was to compare between the standard preoperative bowel preparation (SP) and ERAS protocol in terms of postoperative length of stay (LOS) and postoperative morbidity. Subjects and Methods This was a prospective randomized study was conducted in Ain shams university hospital – Alexandria university hospital involving fifty (50) patients were randomly divided into two equal groups twenty-Five (25) patient in group A follow ERAS protocol and twenty-Five (25) patients in group B following standard protocol. The duration of the study ranged from 6-12 months. Results There was statistically significant difference found between group A and group B regarding the studied parameters ( Readmission in 30 days, Ileus, Vomiting, and UTI) while there was no statistically significant difference between them regarding (early mobilization, urine leakage, dehesince and DVT), there was no statistically significant difference found between group A and group B regarding (Length of stay). Conclusion In patients undergoing radical cystectomy, enhanced recovery protocol is considered as a safe procedure and not associated with any increase in intraoperative and postoperative complications compared to standard protocol. The length of hospital stay was shorter in ERAS group.

Enhanced perioperative care for the prevention of anastomotic leakage – DOUBLE CHECK: study protocol for an international, multicenter open-label trial with historical controls

Background: Colorectal anastomotic leakage (CAL) remains a severe complication after bowel surgery. Recent research has identified several modifiable perioperative CAL risk factors. The aim of this study is to implement an enhanced perioperative care protocol, to optimize the intraoperative condition of the patient and minimalize exposure to modifiable CAL risk factors. Secondly, this study will investigate whether implementation of this new protocol results in a decreased CAL rate. Methods: The DOUBLE CHECK study will be performed using an open-label, international, multicenter design in 11 participating hospitals. The aim is to include an intervention group of 943 adult patients that underwent a colorectal resection with creation of a primary anastomosis. The patients in the intervention group will be treated according to an enhanced perioperative care protocol focusing on optimizing the intraoperative condition of the patient by minimalizing exposure to the following perioperative factors: anemia, hyperglycemia, hypothermia, epidural anesthesia, vasopressor drug administration, and incorrect or lack of antibiotic prophylaxis. The control group will consist of 1562 historical patients that were treated with standard perioperative practice (LekCheck study cohort). The patient’s intraoperative condition defined by exposure to the six perioperative risk factors, compliance to the DOUBLE CHECK study protocol, 30-day and 90-day CAL and other postoperative complications, length of hospital-stay, and ICU stay, hospital readmission and 30-day mortality will be measured. Discussion: The strength of this study is that it is an implementation study of an enhanced perioperative practice protocol for patients that are scheduled for colorectal resection in combination with a comparative study. This protocol could be a tool for other hospitals that want to improve their perioperative care pathway.

Time to Start a New Enhanced Recovery After Surgery (ERAS): A Retrospective Cohort Study.

The enhanced recovery after surgery (ERAS®) is a multimodal perioperative care pathway designed to reduce surgical stress and ultimately improve patient recovery and outcome. It can require significant resources but with proven benefits. The main goal of this study was to perform a diagnostic assessment of perioperative practice in a local colorectal surgical center. 93 patients who underwent elective colorectal surgery from January to December 2022 were analyzed. Preadmission, preoperative, and postoperative data of all patients were collected in a database developed by the researchers, according to ERAS® guidelines. Descriptive statistics were employed to summarize demographic and clinical characteristics. Chi-square and T-test were performed to identify possible associations between categorical variables and postoperative complications. Overall analysis showed deficient preoperative patient optimization, especially regarding nutritional counseling and supplementation, smoking and alcohol cessation, anemia treatment (9%), and pre-anesthetic medication (42%). Removal of invasive devices was significantly delayed (removal of urinary catheter average on the fourthday and surgical drain average on the fifthday) in the postoperatively period and oral intake (average onset on the sixthday). Both contribute to hospital length of stay (mean of 13 days) and a significant number of complications. The results lead us to an individual and multidisciplinary reflection on current practices and outcomes. ERAS® program, already adopted by many centers, could have a positive impact on the immediate postoperative recovery of colorectal patients in Funchal Central Hospital andimplementation seems necessary.

Perioperative care pathway for vulvar reconstruction: a case series

Perioperative care pathway for vulvar reconstruction: a case series

Short-term hypercaloric carbohydrate loading increases surgical stress resilience by inducing FGF21

Dietary restriction promotes resistance to surgical stress in multiple organisms. Counterintuitively, current medical protocols recommend short-term carbohydrate-rich drinks (carbohydrate loading) prior to surgery, part of a multimodal perioperative care pathway designed to enhance surgical recovery. Despite widespread clinical use, preclinical and mechanistic studies on carbohydrate loading in surgical contexts are lacking. Here we demonstrate in ad libitum-fed mice that liquid carbohydrate loading for one week drives reductions in solid food intake, while nearly doubling total caloric intake. Similarly, in humans, simple carbohydrate intake is inversely correlated with dietary protein intake. Carbohydrate loading-induced protein dilution increases expression of hepatic fibroblast growth factor 21 (FGF21) independent of caloric intake, resulting in protection in two models of surgical stress: renal and hepatic ischemia-reperfusion injury. The protection is consistent across male, female, and aged mice. In vivo, amino acid add-back or genetic FGF21 deletion blocks carbohydrate loading-mediated protection from ischemia-reperfusion injury. Finally, carbohydrate loading induction of FGF21 is associated with the induction of the canonical integrated stress response (ATF3/4, NF-kB), and oxidative metabolism (PPARγ). Together, these data support carbohydrate loading drinks prior to surgery and reveal an essential role of protein dilution via FGF21.

Patient experiences during the planned perioperative care pathway: An integrative review.

This integrative review aimed to synthesize evidence about the patients' experiences during the planned perioperative care pathway. Integrative review. Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline Ovid, Scopus, and American Psychological Association (APA) PsychINFO. Original, peer-reviewed studies published in English between 2012 and 2023 exploring patient experiences during the planned perioperative care pathway were reviewed. This review was guided by the Whittemore and Knafl method and followed PRISMA guidelines to search the literature. Twenty-two articles were selected for the final study. Three themes emerged: Sharing of information is empowering; interpersonal relationships are valued by patients, and hospital systems and care co-ordination influence the patient experience. The quality and consistency of the information patients receive can both support and undermine patient confidence in health professionals. The quality of relationships that participants experience and effective communication with health professionals can support or compromise the quality of the patients' perioperative experience. The nature of the hospital systems and care co-ordination in hospital has implications for the quality of recovery from surgery. This review evaluates whether national and international health services and organizations, adhering to the WHO guidelines, have developed and implemented intentionally focused perioperative care with the aims to achieving effective and sustainable surgical outcomes through increased patient satisfaction. This article is an integrative review and does not include patient or public contribution.

Days at home alive after major surgery in patients with and without diabetes: an observational cohort study.

We hypothesized that days at home alive up to 30days after surgery (DAH30), a novel patient-centered outcome metric, as well as long-term mortality, would be impaired in patients with type 1 or 2 diabetes mellitus (DM) undergoing major surgery. This cohort study investigated patients > 18years with and without DM presenting for major non-cardiovascular, non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014. We identified 290,306 patients. Data were matched with various quality registers. The primary outcome was the composite score, DAH30. The secondary outcome was mortality from 31 to 365days. Using multivariable logistic regression, significant independent risk factors influencing the primary and secondary outcomes were identified, and their adjusted odds ratios were calculated. Patients with DM type 1 and 2 had significantly lower DAH30 as compared to non-diabetics. Patients with DM were older, had higher co-morbid burden, and needed more emergency surgery. After adjustment for illness severity and age, the odds of having a DAH30 less than 15, indicating death and/or complications, were significantly increased for both type 1 and type 2 diabetes. In the year after surgery, DM patients had a higher mortality as compared to those without diabetes. The results of this large cohort study are likely broadly generalizable. To optimize patient and societal outcomes, specific perioperative care pathways for patients with diabetes should be evaluated.

Outpatient Spine Surgery: A Narrative Review

In recent years, outpatient spine surgery has gained momentum as a promising approach to improve healthcare value by reducing costs and enhancing patient outcomes. This narrative review presents an updated summary of studies exploring the clinical outcomes and cost savings associated with outpatient spine surgery. Our review highlights the growing acceptance of outpatient spine surgery, which is driven by advancements in surgical techniques, anesthesia protocols, and perioperative care pathways. Several procedures, including lumbar discectomy, lumbar laminectomy plus/minus fusion, anterior cervical decompression and fusion (ACDF), and cervical disc arthroplasty (CDA), have shown success in the outpatient setting. A search strategy was employed to identify relevant studies from the MEDLINE database. Seventeen retrospective cohort studies met the inclusion criteria. Outpatient spine surgery demonstrated favorable clinical outcomes, including lower readmission and reoperation rates, shorter hospital stays, and comparable mortality rates. Additionally, analysis of feasibility outcomes revealed significant cost reductions and decreased operative timing with outpatient procedures. Despite its benefits, challenges persist in implementing outpatient spine surgery. Careful patient selection, standardized protocols, and appropriate financial planning are essential to ensure safe and successful integration into healthcare systems. Patient education and engagement are also crucial for promoting optimal outcomes.

Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care.

Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation. We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams. We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs. We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.

Patients With Down Syndrome and Total Hip and Total Knee Arthroplasty: Outcome Measures Show Increased Risk of Perioperative Complications.

Patients with Down syndrome (DS) are being considered for total joint arthroplasty. There is limited literature regarding outcomes of patients with DS after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Data were abstracted from the 2010 to 2021 Q1 PearlDiver M151 database. THA and TKA osteoarthritis adult patients with and without DS were identified. Patients were matched 1:10. Ninety-day postoperative events and 2-year revision rates were compared. For THA, 154 patients with DS were matched with 1,532 patients without DS. For TKA, 150 patients with DS were matched with 1,495 patients without DS. On multivariable logistic regression, THA and TKA patients with DS were at markedly greater odds of postoperative events including any adverse event, sepsis, minor adverse event, urinary tract infection (UTI), acute kidney injury (AKI), and pneumonia. For both THA and TKA, 2-year revision rates were not increased for those with DS. This study represents the largest cohorts for matched patients with DS undergoing THA or TKA through 90 days postoperatively. For both procedures, DS patients were found to have greater risk of several adverse events, but not 2-year revisions. These findings may help guide perioperative risk assessment, patient/family counseling, and care pathways.

The Enhanced Recovery After Surgery protocol for the perioperative management of pituitary neuroendocrine tumors/pituitary adenomas.

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway that has radically modified the management of patients in multiple surgical specialties. Until now, no ERAS Society guidelines have been formulated for the management of cranial pathologies. During the process of ERAS certification for their neurosurgical department, the authors formulated an ERAS protocol for the perioperative care of patients with pituitary neuroendocrine tumors (PitNET), along with a compliance checklist to monitor the adherence to it and its feasibility. The authors describe the protocol and checklist and report the results, including a cost-minimization analysis, with the application of the ERAS philosophy. The steps that led to the development of this ERAS protocol, including items concerning the preoperative, intraoperative, and postoperative period, are detailed. The authors report their preliminary results through the comparison of the care practice of a historical cohort with a consecutive surgical cohort of patients with PitNET who underwent operation after the implementation of this ERAS protocol. A compliance checklist with key performance indicators was useful to monitor the adherence to the protocol and the changes in the perioperative management. Following the introduction of this ERAS protocol, the authors significantly shortened the duration of the antibiotic therapy (p < 0.00001) and increased the use of mechanical (p < 0.00001) and pharmacological measures to prevent deep venous thrombosis (p = 0.002). The median length of hospital stay was significantly shorter for the ERAS group (p = 0.00014), and there was no increase in readmission rate or postoperative complications. The documentation and data tracking strongly improved in the ERAS cohort and the authors were more attentive in pain evaluation (p = 0.001), postoperative hormonal supplementation (p = 0.001) and early feeding and mobilization (p = 0.0008 and p < 0.00001, respectively). More patients were discharged on day 3 after surgery in the ERAS group (p < 0.00001). The compliance to the whole process increased from 64.2% to 89.5% (p = 0.016), and the compliance per patient was also found to have significantly increased (p < 0.00001). The introduction of a standardized ERAS protocol for the perioperative management of patients with PitNET allowed the authors to improve the multidisciplinary management of these patients. With the application of simple cost-effective interventions and with the avoidance of unnecessary measures, gains were made in terms of early mobilization and feeding, thereby resulting in a shorter in-hospital stay.

Total Hip Arthroplasty in Patients Who Have Marfan Syndrome: Adverse Events and 5-Year Revision Rates

BackgroundMarfan syndrome is a rare inherited connective tissue disease, which may be present in patients who have advanced hip pathologies that may require total hip arthroplasty (THA). The postoperative course of patients who have Marfan syndrome following THA has not yet been defined. MethodsAdult patients who have and do not have Marfan syndrome and underwent THA were identified in a national database. Patients diagnosed who had infection, trauma, or neoplasms within the 90 days prior to surgery were excluded. Those who have versus those who did not have Marfan syndrome were matched 1:10 based on age, sex, and a comorbidity index. After matching, 144 patients who have Marfan syndrome and 1,440 who do not have Marfan syndrome were identified. The 90-day postoperative adverse events and 5-year revisions were assessed and compared with multivariable analyses and log rank tests, respectively. ResultsMultivariable analyses demonstrated that Marfan syndrome was independently associated with greater odds of 90-day adverse events: venous thromboembolic events (odds ratio [OR]: 2.9, P = .001), cardiac events (OR: 4.5, P = .034), pneumonia (OR: 3.5, P < .001), and urinary tract infections (OR: 5.2, P < .001). There was no significant difference in 5-year rates of revision. ConclusionsFollowing THA, Marfan syndrome was independently associated with greater rates of several 90-day adverse events, but not higher 5-year rates of revision. The identified at-risk adverse events may help guide surgeons to improve perioperative care pathways, while having confidence regarding joint survival of THA in this rare disease population.

Emergency department use after outpatient thyroidectomy across three states

BackgroundAlthough outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as “treat-and-release” encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors. MethodsUsing the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission. ResultsOf the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia–related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3–1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1–1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3–3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1–2.2). We observed no associations between these factors and the odds of readmission. ConclusionEmergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.