Perioperative Pathway Research Articles

MP16-17 MULTIMODAL PAIN CONTROL UTILIZING BUPRENORPHINE FOR ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY: A QUALITY IMPROVEMENT COMPARISON TO CONVENTIONAL OPIOID MANAGEMENT

You have accessJournal of UrologyCME1 May 2022MP16-17 MULTIMODAL PAIN CONTROL UTILIZING BUPRENORPHINE FOR ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY: A QUALITY IMPROVEMENT COMPARISON TO CONVENTIONAL OPIOID MANAGEMENT Jo Ann Johnson, Ivan Muchiutti, Sonia Wraich, Aviram Assidon, Akin S. Amasyali, Mohammad Hajiha, Donna Lien, Ruth Belay, Jonathan Maldonado, Ashley Li, Mohamed Keheila, Kanha Shete, Gary Stier, Leonard Soloniuk, Patrick Hogue, Brian Hu, D. Duane Baldwin, and Herbert Ruckle Jo Ann JohnsonJo Ann Johnson More articles by this author , Ivan MuchiuttiIvan Muchiutti More articles by this author , Sonia WraichSonia Wraich More articles by this author , Aviram AssidonAviram Assidon More articles by this author , Akin S. AmasyaliAkin S. Amasyali More articles by this author , Mohammad HajihaMohammad Hajiha More articles by this author , Donna LienDonna Lien More articles by this author , Ruth BelayRuth Belay More articles by this author , Jonathan MaldonadoJonathan Maldonado More articles by this author , Ashley LiAshley Li More articles by this author , Mohamed KeheilaMohamed Keheila More articles by this author , Kanha SheteKanha Shete More articles by this author , Gary StierGary Stier More articles by this author , Leonard SoloniukLeonard Soloniuk More articles by this author , Patrick HoguePatrick Hogue More articles by this author , Brian HuBrian Hu More articles by this author , D. Duane BaldwinD. Duane Baldwin More articles by this author , and Herbert RuckleHerbert Ruckle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The purpose of this multidisciplinary study (urology, anesthesiology and surgical home) is to examine outcomes in patients who received standard mu opioid agonists (control) versus buprenorphine for perioperative pain while undergoing prostatectomy. Buprenorphine is FDA approved for postoperative pain and is uniquely a partial mu opioid agonist with potentially lower opioid side effects including constipation, respiratory depression, dysphoria, and substance abuse. METHODS: Two perioperative analgesic pathways were designed for patients undergoing robotic assisted laparoscopic prostatectomy (RALP). A quality improvement study with retrospectively collected data in a single institution over a 10-month period was performed. The control group (n=39) used standard mu opioid agonists and the intervention group (n=39) used buprenorphine. The patients were surveyed five days after surgery. The primary endpoints were pain scores at discharge and total morphine equivalent dosage (MED). The secondary endpoints included length of stay (LOS), subjective pain control, ileus and patient satisfaction using a Likert scale of 1 (strongly agree) to 5 (strongly disagree). Statistical analysis included Mann-Whitney U and Chi-square, with p<0.05 considered significant. RESULTS: Mean age (66.15 vs. 64.72, p=0.423), BMI (28.9 vs. 29.2, p=0.801) and race distribution (p=0.908) were similar between groups. There was no difference between buprenorphine and the control groups in LOS (1.2 vs. 1.3 days, p=0.414) and length of surgery (262 vs. 272 mins, p=0.501). Buprenorphine had lower reported pain scores at discharge (4.7) compared to the control (5.4) although this did not reach significance (p=0.250). While 73.7% of buprenorphine strongly agreed that their pain was adequately controlled in the hospital, this was 56.4% in the control (p=0.261). There was no difference in overall satisfaction at postoperative day 5 (p=0.312). When analyzing the primary endpoint of MED, buprenorphine received significantly less MED compared to control (15.77 vs. 48.75, p=0.012). There was no significant difference in incidence of ileus between buprenorphine and control (38% vs. 33%, p=0.637). CONCLUSIONS: The use of buprenorphine reduced MED by 67.6% compared to the use of standard mu opioid agonists. This was achieved while maintaining higher patient satisfaction and pain control in buprenorphine compared to control. Source of Funding: Loma Linda University Department of Urology and Department of Anesthesiology © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e282 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jo Ann Johnson More articles by this author Ivan Muchiutti More articles by this author Sonia Wraich More articles by this author Aviram Assidon More articles by this author Akin S. Amasyali More articles by this author Mohammad Hajiha More articles by this author Donna Lien More articles by this author Ruth Belay More articles by this author Jonathan Maldonado More articles by this author Ashley Li More articles by this author Mohamed Keheila More articles by this author Kanha Shete More articles by this author Gary Stier More articles by this author Leonard Soloniuk More articles by this author Patrick Hogue More articles by this author Brian Hu More articles by this author D. Duane Baldwin More articles by this author Herbert Ruckle More articles by this author Expand All Advertisement PDF DownloadLoading ...

Association of Prehabilitation With Postoperative Opioid Use in Colorectal Surgery: An Observational Cohort Study.

Preoperative optimization programs have demonstrated positive effects on perioperative physical function and surgical outcomes. In nonsurgical populations, physical activity and healthy diet may reduce pain and pain medication requirement, but this has not been studied in surgical patients. Our aim was to determine whether a preoperative diet and exercise intervention affects postoperative pain and pain medication use. Patients undergoing abdominal colorectal surgery were invited to participate in a web-based patient engagement program. Those enrolling in the first and third time periods received information on the standard perioperative pathway (enhanced recovery after surgery [ERAS]). Those enrolling in the second time period also received reminders on nutrition and exercise (PREHAB+ERAS). The primary outcome was postoperative inpatient opioid use. The secondary outcomes were inpatient postoperative pain scores and nonopioid pain medication use. The ERAS and PREHAB+ERAS groups were similar in demographic and operative characteristics. Subgroup analysis of patients who activated their accounts demonstrated that the two groups had similar average maximum daily pain scores, but the PREHAB+ERAS group (n=158) used 15.9 fewer oral morphine equivalents per postoperative inpatient day than the ERAS group (n=92), representing a 30% decrease (53mg versus 37.1mg, P=0.04). The two groups used comparable amounts of acetaminophen, gabapentin, and ketorolac. Generalized linear models demonstrated that PREHAB+ERAS, minimally invasive surgery, and older age were associated with lower inpatient opioid use. Access to a web-based preoperative diet and exercise program may reduce inpatient opioid use after major elective colorectal surgery. Further studies are necessary to determine whether the degree of adherence to nutrition and physical activity recommendations has a dose-dependent effect on opioid use.

Prehabilitation before major abdominal surgery: Evaluation of the impact of a perioperative clinical pathway, a pilot study.

Major abdominal surgery morbidity can reach 50%. Prehabilitation has shown promising results in decreasing complications. However, it is unknown if prehabilitation can have a positive effect specifically after major abdominal surgery. The goal of this study was to evaluate the feasibility and safety of a prehabilitation program before major abdominal surgery. All patients evaluated for major abdominal surgery between February and April 2018 were eligible. A 4-week trimodal prehabilitation program combining physical therapy, nutritional support and psychological preparation was set up. Among 106 patients evaluated for major abdominal surgery during the study period, 60 were included in the prehabilitation program. No cardiovascular events occurred during prehabilitation. The 6-min walking distance increased significantly (+45 m, increase of 9.3%, p = 0.008) after prehabilitation (and before the operation). Anxiety, depression, and several quality of life (QoL) items improved. Postoperative 90-day mortality and morbidity were 3.4% and 48%, respectively. Median hospital length of stay, and intensive care unit length of stay were 14 and 6 days, respectively. For 19 patients readmitted, the treatment was medical, radiological, or surgical, for 11, 5, and 3 patients, respectively. Prehabilitation before major abdominal surgery is feasible, safe, and improve patients' functional reserves, QoL, and psychological status.

Laparoscopic right colectomy: changes in surgical technique and perioperative management allow better postoperative results in a comparative series of 361 patients.

To compare the short-term outcomes in patients who underwent laparoscopic right colectomy with a traditional minimally invasive approach versus patients who underwent a laparoscopic colectomy with an enhanced perioperative pathway. A retrospective analysis was conducted on a consecutive series of patients who underwent elective laparoscopic right colectomy for neoplastic disease between January 1, 2011 and December 31, 2020. The patients were divided into two groups: the first cohort (FC), who underwent a traditional laparoscopic colectomy, mainly with extracorporeal anastomosis, between January 1, 2011 and December 31, 2015 and the second cohort (SC), who underwent a laparoscopic colectomy with an enhanced intraoperative (intracorporeal anastomosis) and perioperative pathway (ERAS protocol) between January 1, 2016 and December 31, 2020. There were a total of 361 patients, including 177 in the FC and 184 in the SC. In the SC a higher number of intracorporeal anastomoses was performed (91.8% vs. 19.2%, p < 0.001), drains were placed in 42 patients only (22.8% vs. 100% in the FC) and nasogastric tubes were placed in 21 patients only (11.4% vs. 100% in the FC). In the initial period of the SC. the procedures required a slightly longer operative time (median 105 vs. 95min; p = 0.002), but postoperative surgical complications were lower (12% vs. 17.4%, p = 0.179). Postoperative recovery was faster in SC along with time to discharge (4 vs. 7days; p < 0.001). Intraoperative anastomosis and enhanced pathways in right laparoscopic colectomy seem to guarantee better results with lower surgical complications and faster postoperative recovery.

Perioperative Experiences of Transgender Adults Seeking Gender-Affirming Surgery: A Qualitative Interview Study.

Transgender individuals have been systemically excluded from U.S. health care, creating barriers and disparities that other populations do not face. Gender-affirming surgery represents an emerging treatment modality for gender dysphoria, however, little is known about how transgender patients experience the perioperative pathway. This study sought to characterize the experiences of transgender patients seeking gender-affirming surgery and identify opportunities for improvement. A qualitative study was conducted at an academic medical center between July and December 2020. Semistructured interviews were conducted after a postoperative encounter with adult patients who had undergone gender-affirming surgery within the past year. A purposive sampling strategy was used to maximize representation across surgery types and surgeons. Recruitment continued until thematic saturation was reached. All invited patients agreed to participate, yielding 36 interviews (response rate=100%). Four major themes emerged. First, gender-affirming surgery was described as a major life event, often reflecting years of personal decision making and research. Second, participants stressed the importance of surgeon investment, surgeon experience caring for transgender patients, and individualized care in developing a strong relationship with their care team. Third, self-advocacy was necessary to navigate the perioperative pathway and overcome barriers. Last, participants discussed a lack of equity and provider awareness regarding transgender health issues, including correct pronoun usage, terminology, and insurance coverage. Patients undergoing gender-affirming surgery encounter unique perioperative barriers to care, which would benefit from targeted interventions in the health care system. To improve the pathway, our findings support the creation of multidisciplinary gender-affirmation clinics, greater emphasis on transgender care in medical education, and insurance policy reforms aimed at promoting consistent and equitable coverage.

Perioperative management for people with kidney failure receiving dialysis: A scoping review.

People with kidney failure receiving dialysis (CKD-G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD-G5D. We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD-G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design. We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant-related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non-randomized study designs. Despite many current gaps in perioperative research for patients with CKD-G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non-randomized studies. Our review may inform organization of evidence-based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address.

Hospital-Based Rapid Recovery Protocol in Knee Arthroplasty

This review aims to determine the elements a hospital-based knee arthroplasty program should consider when developing a rapid recovery protocol. It will examine the perioperative pathway and how a program can break down each phase for success. Secondary objectives of this review include how and why the culture surrounding knee arthroplasty has changed and why it is in a hospital's best interest to adopt a rapid recovery pathway in light of this new landscape. An extensive search was performed through databases which included Still OneSearch, EBSCOhost, and PubMed. Sources aligned with the review's objectives. Inclusion criteria involved primary sources, secondary sources, and peer-reviewed articles less than 5 years old. On finding primary and secondary sources, reference sections provided additional materials to ensure high-quality research. Outpatient knee arthroplasty has gained interest in the past 10 years, and rapid recovery protocols have helped promote this likely development. The rapidly changing landscape surrounding knee arthroplasty was triggered by insurance companies and pushed even further because of the COVID-19 pandemic. Developing a rapid recovery protocol in the hospital setting involves a change in overall culture, interprofessional participation, and patient and family cooperation. Although not an easy task, adopting a rapid recovery protocol for knee arthroplasty has been shown to improve overall patient outcomes by decreasing length of stay, decreasing complications, and increasing discharge home rates. Along with improved outcomes, we have improvements in patient satisfaction and overall cost savings.

Nurse-led randomised controlled trials in the perioperative setting: A scoping review

Purpose: Nurses provide care at each phase of the complex perioperative pathway and are well placed to identify areas of care requiring investigation in randomised controlled trials. Yet, currently, the scope of nurse-led randomised controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomised controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation.

Electrolyte and Acid–Base Disturbances in Emergency High‐Risk Abdominal Surgery, a Retrospective Study

Patients undergoing emergency high-risk abdominal surgery potentially suffer from both systemic dehydration and hypovolaemia. Data on the prevalence and clinical impact of electrolyte disturbances in this patient group, specifically the differences in patients with intestinal obstruction (IO) versus perforated viscus (PV) are lacking. Adult patients undergoing emergency high-risk abdominal surgery in a standardized perioperative pathway were included in this retrospective single-center cohort study. Electrolytes and arterial blood gas analysis were measured during the early perioperative period. Prevalence and clinical impact of electrolyte disturbances were assessed. A total of 354 patients were included in the study. Preoperative alkalemia dominated preoperatively, significantly more prevalent in IO (45 vs. 32%, p < .001), while acidosis was most pronounced postoperatively in PV (49 vs. 28%, p < .0001). Preoperative hypochloraemia and hypokalemia were more frequent in the IO (34 vs. 20% and 37 vs. 25%, respectively). Hyponatremia was highly prevalent in both IO and PV. Pre- and postoperative hypochloremia were independently associated with 30-day postoperative morbidity and mortality in patients with IO (OR 2.87 (1.35, 6.23) p = 0.006, OR 6.86 (1.71, 32.2) p = 0.009, respectively). Hypochloremic patients presented with reduced long-term survival as compared with the normo- and hyperchloremic patients (p < 0.05). Neither plasma sodium nor potassium showed asignificant association with outcome. These observations suggest that acute high-risk abdominal patients have frequent preoperative alkalosis shifting to postoperative acidosis. Both pre- and postoperative hypochloremia were independently associated with both impaired short- and long-term outcome in patients with intestinal obstruction, with potential implications for the choice of resuscitations fluids.

Quality performance indicators for the surgical treatment of gastric adenocarcinoma: a systematic review.

BackgroundA systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of gastric adenocarcinoma (GA) with the aim of defining a set of QPIs that can be used to assist in the accreditation of institutions for training, allow cross jurisdiction comparison of treatment and outcomes, as well as provide a basis to develop quality improvement programs. These QPI's capture key components of patient care that are fundamental to overall outcome.MethodsA systematic literature review was conducted searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1 August 2021 included. Search terms utilized were ‘Quality of health care OR Quality improvement or Quality control OR Quality indicators’, AND ‘Gastrectomy’ OR ‘Stomach neoplasm’ OR ‘Adenocarcinoma’ OR ‘Gastric resection’ OR ‘Gastric cancer’.ResultsTwelve articles were included in the final analysis. The selected studies included editorials (n = 2), retrospective review of institutional experience (n = 5), cohort studies (n = 2), survey methodology (n = 1), expert guidelines (n = 1) and consensus statement (n = 1). For GC QPIs, process measures included patient discussion at multi‐disciplinary meetings, access to perioperative multimodal diagnostic pathways, and specific surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay.ConclusionsThere is a relative paucity of internationally agreed QPI for the surgical management of gastric adenocarcinoma. The data from this review will form the basis of a project to develop internationally agreed and feasible QPI for gastric cancer resections.

Physical and Psychological Health Behavior Changes During the COVID-19 Pandemic that May Inform Surgical Prehabilitation: a Narrative Review.

Purpose of ReviewMultimodal prehabilitation aims to improve preoperative health in ways that reduce surgical complications and expedite post-operative recovery. However, the extent to which preoperative health has been affected by the COVID-19 pandemic is unclear and evidence for the mitigating effects of prehabilitation in this context has not been elucidated. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. Delayed diagnosis and surgery have caused a backlog of cases awaiting surgery increasing the risk of more complex procedures due to disease progression. Poor fitness and preoperative deconditioning are predictive of surgical complications and may be compounded by pandemic-related restrictions to accessing supportive services. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. This narrative review aims to summarize the understanding of the effects of the COVID-19 pandemic on preoperative health and related behaviors and their implication for the need and delivery for prehabilitation to engender improved surgical outcomes. A literature search of Medline was conducted for articles related to preoperative health, prehabilitation, and surgical outcomes published between December 1, 2020 and January 31, 2021. Additional hand searches for relevant publications within the included literature were also conducted through October 15, 2021.Recent FindingsThe COVID-19 pandemic, and measures designed to reduce the spread of the virus, have resulted in physical deconditioning, deleterious dietary changes, substance misuse, and heightened anxiety prior to surgery. Due to the adverse health changes prior to surgery, and often protracted waiting time for surgery, there is likely an elevated risk of peri- and post-operative complications. A small number of prehabilitation services and research programmes have been rapidly adapted or implemented to address these needs.SummaryDuring the COVID-19 pandemic to date, people undergoing surgery have faced a triple threat posed by extended wait times for surgery, reduced access to supportive services, and an elevated risk of poor outcomes. It is imperative that healthcare providers find ways to employ evidence-based prehabilitation strategies that are accessible and safe to mitigate the negative impact of the pandemic on surgical outcomes. Attention should be paid to cohorts most affected by established health inequities and further exacerbated by the pandemic.

Safety and feasibility of same-day discharge laparoscopic radical prostatectomy: a systematic review.

PurposeDay case or same-day discharge (SDD) pure laparoscopic or robot-assisted radical prostatectomy (RP) has risen over the last few years with the aim of discharging patients within 24 h, reducing costs and length of stay, and facilitating return to active life. We perform a systematic review of literature to evaluate the feasibility of SDD RP.MethodsA systematic review search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Embase. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.ResultsBased on the literature search of 509 articles, 12 (1378 patients) met the inclusion criteria (mean age: 63 years). All studies were unicentric except one. The mean SDD surgeries experience per centre was 66 cases .The means operative time and blood loss were 154 min and 126.5 ml, respectively. Mean SDD failure was 7.4%. Concomitant lymph node dissection was performed in 56.2%. The overall complication rate was 10.2% of cases; with a majority of Clavien grade I or II. Mean readmission rate after discharge was 5%. SDD generated cost reductions compared to inpatient surgery with variable differences according to the considered healthcare system.ConclusionsDay-case RP is a safe and feasible strategy in selected cases with multicentre proofs of concept. Its widespread use in routine practice needs further research due to biases in patient selection. Implementation of peri-operative pathways such as ERAS and prehabilitation improves patient adherence to SDD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00345-022-03944-1.

Racial disparity in causes for readmission following bariatric surgery.

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood. Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients. Academic hospital. We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching. More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001). Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

Quality of Life in Patients With Rectal Resections and End-to-End Primary Anastomosis Using a Standardized Perioperative Pathway.

Objectives: Lower rectal resection is associated with a high rate of postoperative complications and, therefore, adversely impacts the postoperative health-related quality of life (QoL). Though sporadically practiced in different centers, there is no standard perioperative protocol for the management of patients with rectal growths. The aim of this analysis is to evaluate the patient-reported outcomes after low rectal resections followed by an end-to-end-reconstruction and temporary covering ileostomy using a multidisciplinary fail-safe-concept.Methods: Between 2015 and 2020, we evaluated patient reported outcomes after open and laparoscopic rectal resections with end-to-end reconstruction with a primary straight anastomosis using a standardized perioperative pathway All patients with stoma were excluded from the study. The data for the QoL of patients was collected using the established Low Anterior Resection Syndrome (LARS)-score and the EORTC-C30 and CR-29 questionnaires at a single postoperative timepoint.Results: We recruited 78 stoma-free patients for this analysis. Of 78 patients included in the study, 87.2% were operated laparoscopically and the mean global health status was 67.95 points, while a major LARS was detected in 48 (61.5%) patients. No anastomotic leakage (AL) occurred within the study cohort. There was no significant change in the LARS-score or the global health status depending on the follow-up-period.Conclusion: This study shows that good QoL and functional outcomes with no AL are achievable following end-to-end straight anastomosis using a standardized perioperative surgical fail-safe protocol procedure.

Peri-operative management of patients with Parkinson's disease.

Patients with Parkinson's disease are at higher risk of peri-operative medical and surgical complications. Multidisciplinary management, early recognition of potential complications, specialised care of medications and intra-operative protection of the vulnerable brain are all important aspects of the peri-operative management of patients with Parkinson's disease. Advances in continuous dopaminergic treatment, development of a peri-operative Parkinson's disease pathway and application of telemedicine are starting to play a role in improving peri-operative care. Management of patients with advanced Parkinson's disease is also evolving, with potential for incorporation of integrated care and changes in the anaesthetic management for deep brain stimulation surgery. There are new methods for localisation of target nuclei and increasing insight on the effects of anaesthetic drugs on microelectrode recordings and clinical outcomes. Parkinson's disease is a progressive disease, but management is improving with better peri-operative care for patients.

Multimodal prehabilitation before major abdominal surgery: A retrospective study

Prehabilitation may benefit older patients undergoing major surgeries. Currently, its efficacy has not been conclusively proven. This is a retrospective review of a multimodal prehabilitation programme. Patients aged 65 years and above undergoing major abdominal surgery between May 2015 and December 2019 in the National University Hospital were included in our institutional programme that incorporated aspects of multimodal prehabilitation and Enhanced Recovery After Surgery concepts as 1 holistic perioperative pathway to deal with issues specific to older patients. Physical therapy, nutritional advice and psychosocial support were provided as part of prehabilitation. There were 335 patients in the prehabilitation cohort and 256 patients whose records were reviewed as control. No difference in postoperative length of stay (P=0.150) or major complications (P=0.690) were noted. Patients in the prehabilitation group were observed to ambulate a longer distance and participate more actively with their physiotherapists from postoperative day 1 until 4. In the subgroup of patients with cancer, more patients had undergone neoadjuvant therapy in the prehabilitation group compared to the control group (21.7% versus 12.6%, P=0.009). Prehabilitation patients were more likely to proceed to adjuvant chemotherapy (prehabilitation 87.2% vs control 65.6%, P<0.001) if it had been recommended. The current study found no differences in traditional surgical outcome measures with and without prehabilitation. An increase in patient mobility in the immediate postoperative period was noted with prehabilitation, as well as an association between prehabilitation and increased adherence to postoperative adjuvant therapy. Larger prospective studies will be needed to validate the findings of this retrospective review.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer.

BackgroundUnintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.MethodsWe retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.ResultsOf the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.ConclusionsResults of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

Polymorphic Variants in the GRK5 Gene Promoter Are Associated With Diastolic Dysfunction in Coronary Artery Bypass Graft Surgery Patients.

The G-protein-coupled receptor kinase 5 (GRK5) is a mediator of cardiovascular homeostasis and participates in inflammation and cardiac fibrosis, both being involved in the development of diastolic dysfunction (DD). While mechanisms of transcriptional regulation of the GRK5 promoter are unclear, we tested the hypotheses, that (1) GRK5 expression varies depending on functional single nucleotide polymorphisms (SNPs) in the GRK5 promoter and (2) this is associated with DD in patients undergoing coronary artery bypass graft (CABG) surgery. We amplified and sequenced the GRK5 promoter followed by cloning, reporter assays, and electrophoretic mobility shift assays (EMSA). GRK5 messenger ribonucleic acid (mRNA) expression was determined in right atrial tissue sampled from 50 patients undergoing CABG surgery. In another prospective study, GRK5 genotypes were associated with determinants of diastolic function using transesophageal echocardiography in 255 patients with CABG with normal systolic left ventricular (LV) function. Specifically, we measured ejection fraction (EF), transmitral Doppler early filling velocity (E), tissue Doppler early diastolic lateral mitral annular velocity (E' lateral), and calculated E/E', E' norm and the difference of E' lateral and E' norm to account for age-related changes in diastolic function. We identified 6 SNPs creating 3 novel haplotypes with the greatest promoter activation in haplotype tagging (ht) SNP T(-678)C T-allele constructs (P < .001). EMSAs showed allele-specific transcription factor binding proving functional activity. GRK5 mRNA expression was greatest in TT genotypes (TT: 131 fg/µg [95% CI, 108-154]; CT: 109 [95% confidence interval {CI}, 93-124]; CC: 83 [95% CI, 54-112]; P = .012). Moreover, GRK5 genotypes were significantly associated with determinants of diastolic function. Grading of DD revealed more grade 3 patients in TT compared to CT and CC genotypes (58% vs 38% vs 4%; P = .023). E´ lateral was lowest in TT genotypes (P = .007) and corresponding E/E' measurements showed 1.27-fold increased values in TT versus CC genotypes (P = .01), respectively. While E' norm values were not different between genotypes (P = .182), the difference between E' lateral and E' norm was significantly higher in TT genotypes compared to CC and CT genotypes (-1.2 [interquartile range {IQR}, 2.7], -0.5 [IQR, 3.4], and -0.4 [IQR, 4.2; P = .035], respectively). A functional GRK5 SNP results in allele-dependent differences in GRK5 promoter activity and mRNA expression. This is associated with altered echocardiographic determinants of diastolic function. Thus, SNPs in the GRK5 promoter are associated with altered perioperative diastolic cardiac function. In the future, preoperative testing for these and other SNPs might allow to initiate more specific diagnostic and perioperative pathways to benefit patients at risk.

Ultrasound-Guided Continuous Bilateral Erector Spinae Plane Blocks Are Associated with Reduced Opioid Consumption and Length of Stay for Open Cardiac Surgery: A Retrospective Cohort Study.

This study tested the hypothesis that continuous bilateral erector spinae plane blocks placed preoperatively would reduce opioid consumption and improve outcomes compared with standard practice in open cardiac surgery patients. Patients who received bilateral continuous erector spinae plane blocks for primary open coronary bypass, aortic valve, or ascending aortic surgery were compared to a historical control group. Patients in the block group received a 0.5% ropivacaine bolus preoperatively followed by a 0.2% ropivacaine infusion begun postoperatively. No other changes were made to the perioperative care protocol. The primary outcome was opioid consumption. Secondary outcomes were time to extubation and length of stay. Twenty-eight patients received continuous erector spinae plane blocks and fifty patients served as historic controls. Patients who received blocks consumed less opioids, expressed as oral morphine equivalents, both intraoperatively (34 ± 17 vs. 224 ± 125 mg) and during their hospitalization (224 ± 108 vs. 461 ± 185 mg). Patients who received blocks had shorter times to extubation (126 ± 87 vs. 257 ± 188 min) and lengths of stay in the intensive care unit (35 ± 17 vs. 58 ± 42 h) and hospital (5.6 ± 1.6 vs. 7.7 ± 4.6 days). Continuous erector spinae plane blocks placed prior to open cardiac surgical procedures reduced opioid consumption, time to extubation, and length of stay compared to a standard perioperative pathway.

Evolution of Perioperative Pathways in Cranial Vault Remodeling

Evolution of Perioperative Pathways in Cranial Vault Remodeling