Surgery Pathway Research Articles

Short-term outcomes of an enhanced recovery after surgery pathway for children with congenital scoliosis undergoing posterior spinal fusion: a case-control study of 70 patients.

Increasing evidence demonstrates the advantages of an enhanced recovery after surgery (ERAS) protocol; however, few studies have evaluated ERAS in pediatric patients. This study aimed to evaluate the effect of ERAS in pediatric patients with congenital scoliosis. Seventy pediatric patients with congenital scoliosis underwent posterior hemivertebra resection and fusion with pedicle screws and were prospectively randomly assigned to the ERAS group ( n = 35) and control group ( n = 35). ERAS management comprised 15 elements including a shortened fasting time, optimized anesthesia protocol, and multimodal analgesia. The control group received traditional perioperative management. Clinical outcome was evaluated by hospital stay, surgery-related indicators, diet, pain scores, laboratory tests, and complications. The surgical outcome showed a similar correction rate in the ERAS group (84.0%) and control group (89.0%; P = 0.471). The mean fasting time was significantly shorter in the ERAS group than in the control group. Compared with the control group, the ERAS group had significantly shorter mean times to postoperative hospital stay, first anal exhaust and defecation, significantly lower mean pain scores in the first 2 days postoperatively ( P < 0.05), and a significantly lower mean interleukin-6 concentration on postoperative day 1 ( P < 0.001). The incidence of complications was similar in the ERAS group and control group ( P > 0.05). The ERAS protocol is effective and safe for pediatric patients with congenital spinal deformity and may significantly improve the treatment efficacy compared with traditional perioperative management methods. Levels of Evidence: III.

Community-wide feasibility of the Lower Extremity Amputation Protocol amongst vascular amputees

BackgroundThe Lower Extremity Amputation Protocol (LEAP) is a multidisciplinary enhanced recovery after surgery pathway for vascular amputees. The objective of this study was to examine feasibility and outcomes of community-wide implementation of LEAP. MethodsLEAP was implemented at three safety net hospitals for patients with peripheral artery disease or diabetes requiring major lower extremity amputation. Patients who underwent LEAP (LEAP) were matched 1:1 with retrospective controls (NOLEAP) on hospital location, need for initial guillotine amputation, and final amputation type (above- vs below-knee). Primary endpoint was postoperative hospital length of stay (PO-LOS). ResultsA total of 126 amputees (63 LEAP and 63 NOLEAP) were included with no difference between baseline demographics and co-morbidities between the groups. After matching, both groups had the same prevalence of amputation level (76% below-knee vs 24% above-knee). LEAP patients had shorter duration of postamputation bed rest (P = .003) and were more likely to receive limb protectors (100% vs 40%; P ≤ .001), prosthetic counseling (100% vs 14%; P ≤ .001), perioperative nerve blocks (75% vs 25%; P ≤ .001), and postoperative gabapentin (79% vs 50%; P ≤ .001). Compared with NOLEAP, LEAP patients were more likely to be discharged to an acute rehabilitation facility (70% vs 44%; P = .009) and less likely to be discharged to a skilled nursing facility (14% vs 35%; P = .009). The median PO-LOS for the overall cohort was 4 days. LEAP patients had a shorter median PO-LOS (3 [interquartile range, 2-5] vs 5 [interquartile range, 4-9] days; P < .001). On multivariable logistic regression, LEAP decreased the odds of a PO-LOS of ≥4 days by 77% (odds ratio, 0.23; 95% confidence interval, 0.09-0.63). Overall, LEAP patients were significantly less likely to have phantom limb pain (5% vs 21%; P = .02) and were more likely to receive a prosthesis (81% vs 40%; P ≤ .001). In a multivariable Cox proportional hazards model, LEAP was associated with an 84% reduction in time to receipt of prosthesis (hazard ratio, 0.16; 95% confidence interval, 0.085-0.303; P < .001). ConclusionsCommunity wide implementation of LEAP significantly improved outcomes for vascular amputees demonstrating that utilization of core ERAS principles in vascular patients leads to decreased PO-LOS and improved pain control. LEAP also affords this socioeconomically disadvantaged population a greater opportunity to receive a prosthesis and return to the community as a functional ambulator.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BackgroundPatients’ expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.ObjectiveThis study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.Materials and methodsAll consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.ResultsIn total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).ConclusionEnhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients’ concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Implementation of enhanced recovery after surgery pathway for patients undergoing mastectomy.

Mastectomy is still a common treatment for breast cancer. The introduction of the Enhanced Recovery After Surgery pathway (ERAS) having proven its benefits for major surgeries has not yet been validated for mastectomy without reconstruction. Our study was conducted to investigate the effects of implementing an ERAS pathway for mastectomies, including the length of hospital stay, postoperative complications and patient satisfaction. The study population included all patients who underwent mastectomy without immediate breast reconstruction in the gynecological surgery department of the Tours University Hospital during the year 2020. We compared patients who underwent an ERAS protocol with those who were managed in a standard manner. Of the 92 patients managed for mastectomy, 32 were managed in the ERAS group. The two groups were comparable. We found fewer postoperative complications with this protocol in multivariate analysis. We also obtained a 37% response rate to the satisfaction questionnaires. We did not find any significant difference between the 2 groups. There is a trend towards a decrease in the length of hospitalization associated with a decrease in postoperative complications thanks to the implementation of a ERAS protocol for the management of mastectomies. Future studies should focus on both objective clinical outcomes and patient-reported experiences to provide a comprehensive understanding of the effectiveness of ERAS protocols in mastectomy patients.

How much narcotics are really needed after bariatric surgery: results of a prospective study.

To mitigate the opioid crisis, physicians are reevaluating opioid prescribing patterns. To evaluate outcomes of maximal opioid reduction on top of an existing Enhanced Recovery after Surgery (ERAS) pathway in our The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery program. Academic tertiary care hospital, United States. Patients undergoing primary bariatric operation were studied from July 2017 to April 2019, (standard ERAS cohort), and compared to patients from April 2019 to February 2021 (standard ERAS with Sparing Opioid Use Postoperatively protocol) (SOUP cohort). The primary endpoint was reduction of perioperative opioid use. Of 367 patients, 212 (57.8%) and 155 (42.2%) were in the ERAS and SOUP cohorts, respectively. Roux-en-Y gastric bypass was 48.6% (n = 103) versus 54.2% (n = 84) and sleeve gastrectomy was 51.4% (n = 109) versus 45.8% (n = 71) for ERAS versus SOUP, respectively (P = .29). The SOUP cohort of patients required a low median inpatient morphine equivalent dose of 4 mg [0-6.2]. The ERAS cohort was discharged on a higher morphine equivalent dose than the SOUP cohort at 186.7 mg ± 92.9 versus 37.6 ± 32.3 (P < .05), and median consumption of the standard 5 mg oxycodone tablet was 1.5 tablets [0-4]. The SOUP cohort patients rated their pain satisfaction score on a scale of 1 to 10 at 9.1 points (standard deviation ± 1.8). The SOUP cohort had a shorter length of stay (P < .05), with comparable readmission rates. An opioid-sparing protocol can be implemented after bariatric surgery with high overall satisfaction with pain control.

Comment on: The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database.

Comment on: The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database.

Association Between Mobilization and Composite Postoperative Complications Following Major Elective Surgery

Mobilization after surgery is a key component of Enhanced Recovery after Surgery (ERAS) pathways. To evaluate the association between mobilization and a collapsed composite of postoperative complications in patients recovering from major elective surgery as well as hospital length of stay, cumulative pain scores, and 30-day readmission rates. This retrospective observational study conducted at a single quaternary US referral center included patients who had elective surgery between February 2017 and October 2020. Mobilization was assessed over the first 48 postoperative hours with wearable accelerometers, and outcomes were assessed throughout hospitalization. Patients who had elective surgery lasting at least 2 hours followed by at least 48 hours of hospitalization were included. A minimum of 12 hours of continuous accelerometer monitoring was required without missing confounding variables or key data. Among 16 203 potential participants, 8653 who met inclusion criteria were included in the final analysis. Data were analyzed from February 2017 to October 2020. Amount of mobilization per hour for 48 postoperative hours. The primary outcome was a composite of myocardial injury, ileus, stroke, venous thromboembolism, pulmonary complications, and all-cause in-hospital mortality. Secondary outcomes included hospital length of stay, cumulative pain scores, and 30-day readmission. Of 8653 included patients (mean [SD] age, 57.6 [16.0] years; 4535 [52.4%] female), 633 (7.3%) experienced the primary outcome. Mobilization time was a median (IQR) of 3.9 (1.7-7.8) minutes per monitored hour overall, 3.2 (0.9-7.4) in patients who experienced the primary outcome, and 4.1 (1.8-7.9) in those who did not. There was a significant association between postoperative mobilization and the composite outcome (hazard ratio [HR], 0.75; 95% CI, 0.67-0.84; P < .001) for each 4-minute increase in mobilization. Mobilization was associated with an estimated median reduction in the duration of hospitalization by 0.12 days (95% CI, 0.09-0.15; P < .001) for each 4-minute increase in mobilization. The were no associations between mobilization and pain score or 30-day readmission. In this study, mobilization measured by wearable accelerometers was associated with fewer postoperative complications and shorter hospital length of stay.

Same-day discharge pathway for breast cancer surgery in patients aged over 80: A feasibility study

The therapeutic strategy in older adults with breast cancer (BC) has always sought to be a model of personalized medicine. The first example was primary endocrine therapy, a less aggressive treatment targeting a biomarker in a frail patient [ [1] Preece P.E. Wood R.A. Mackie C.R. Cuschieri A. Tamoxifen as initial sole treatment of localised breast cancer in elderly women: a pilot study. Br Med J (Clin Res Ed). 1982 Mar 20; 284: 869-870https://doi.org/10.1136/bmj.284.6319.869-a Crossref PubMed Scopus (154) Google Scholar ]. Recently, there have been further proposals to de-escalate surgical procedures, to the extreme of considering omitting surgery altogether [ [2] LeMasters T.J. Madhavan S.S. Sambamoorthi U. Vyas A.M. Disparities in the initial local treatment of older women with early-stage breast Cancer: a population-based study. J Womens Health (Larchmt). 2017 Jul; 26: 735-744https://doi.org/10.1089/jwh.2015.5639 Crossref Scopus (10) Google Scholar , [3] Matar R. Barrio A.V. Sevilimedu V. Le T. Heerdt A. Morrow M. et al. Can we successfully De-escalate axillary surgery in women aged ≥ 70 years with ductal carcinoma in situ or early-stage breast Cancer undergoing mastectomy?. Ann Surg Oncol. 2022 Apr; 29: 2263-2272https://doi.org/10.1245/s10434-021-11140-5 Crossref Scopus (1) Google Scholar ]. However, studies have found a negative impact of omission of surgery on survival and quality-of-life in older patients[ 4 Ward S.E. Richards P.D. Morgan J.L. Holmes G.R. Broggio J.W. Collins K. et al. Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer-specific survival. Br J Surg. 2018 Oct; 105: 1454-1463https://doi.org/10.1002/bjs.10885 Crossref PubMed Scopus (25) Google Scholar , 5 Wyld L. Reed M.W.R. Morgan J. Collins K. Ward S. Holmes G.R. et al. Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life. Eur J Cancer. 2021 Jan; 142: 48-62https://doi.org/10.1016/j.ejca.2020.10.015 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar , 6 Osório F. Barros A.S. Peleteiro B. Barradas A.R. Urbano J. Fougo J.L. et al. Frailty-independent Undertreatment negative impact on survival in older patients with breast Cancer. J Breast Cancer. 2021 Dec; 24: 542-553https://doi.org/10.4048/jbc.2021.24.e45 Crossref Scopus (1) Google Scholar ].

Enhanced recovery after surgery pathway with modified biportal endoscopic transforaminal lumbar interbody fusion using a large cage. Comparative study with minimally invasive microscopic transforaminal lumbar interbody fusion.

Studies about the clinical efficacy of endoscopic lumbar interbody fusion using an enhanced recovery after surgery (ERAS) pathway are insufficient. Thus, the purpose of this study was to investigate clinical usefulness of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using an ERAS compared with microscopic TLIF. Prospectively collected data were retrospectively analyzed. Patients who received modified biportal endoscopic TLIF with ERAS were grouped into an endoscopic TLIF group. Those who received microscopic TLIF without ERAS were grouped into a microscopic TLIF group. Clinical and radiologic parameters were compared between two groups. Fusion rate was evaluated using sagittal reconstruction images of postoperative computed tomographic (CT) scan. There were 32 patients in the endoscopic TLIF group with ERAS and 41 patients in the microscopic TLIF group without ERAS. Visual analog scale (VAS) scores for back pain preoperatively at day one and day two were significantly (p < 0.05) higher in the non-ERAS microscopic TLIF group than in the ERAS endoscopic TLIF group. Preoperative Oswestry Disability Index were significantly improved at the last follow-up in both groups. The fusion rate at postoperative one year was 87.5% in the endoscopic TLIF group and 85.4% in the microscopic TLIF group. Biportal endoscopic TLIF with ERAS pathway may have good aspect to accelerate recovery after surgery. There was no inferiority of fusion rate of endoscopic TLIF comparing to microscopic TLIF. Biportal endoscopic TLIF using a large cage with ERAS pathway may be a good alternative treatment for lumbar degenerative disease.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Enucleación prostática con láser de holmio (HoLEP) mediante cirugía sin ingreso: una alternativa posible y segura

ObjectiveTo study the feasibility of holmium laser enucleation (HoLEP) performed as a same-day surgery. Material and methodsProspective observational study including 25 patients submitted to HoLEP. Patients were discharged the same day if they met the established criteria. ResultsThe mean age of the patients was 65.1 years and prostate volume was 45.8cc. All patients were discharged the same day of surgery. The overall complication rate at 30 days was 12% (Clavien I 100%). The rate of re-hospitalization was 0%. Patient satisfaction rate with the day surgery pathway was 95%. ConclusionsThe initial analysis of our results suggests that outpatient HoLEP is a safe and effective alternative with low rate of complications. According to satisfaction rates, patients prefer the day surgery pathway for the performance of HoLEP.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective.

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations. Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%). Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance. This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery

Venous thromboembolism is a life-threatening complication of surgery. An Enhanced Recovery After Surgery program is a multimodal care pathway that facilitates faster recovery from surgery. The rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery program is unknown. This study aimed to evaluate the rate of venous thromboembolism within 30 days of gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center. Data were collected prospectively on Enhanced Recovery After Surgery pathway gynecologic patients undergoing open surgery (November 3, 2014, to March 31, 2021) and minimally invasive surgery (February 1, 2017, to March 31, 2021). Care was delivered at a tertiary cancer care center located in a large urban area. Patients undergoing emergency surgery or multispecialty surgeries were excluded. Patients undergoing open surgery were to receive heparin prophylaxis before surgery, sequential compression devices during surgery and admission, and low-molecular-weight heparin prophylaxis during admission. If diagnosed with malignancy, patients were to receive extended venous thromboembolism prophylaxis for 28 days after surgery. For minimally invasive surgery, patients received only sequential compression devices during surgery and no heparin prophylaxis before or after surgery. Venous thromboembolism events were included if detected on imaging obtained for symptoms or other indications. Descriptive statistics and bivariate statistical analyses were performed. Of 3329 patients, 1519 (45.6%) underwent laparotomy, 1452 (43.6%) underwent laparoscopy, and 358 (10.8%) underwent robotic surgery. The incidence rates of venous thromboembolism were 0.6% (n=21; 95% confidence interval, 0.4%-0.9%) overall, 1.1% (n=16, 95% confidence interval, 0.6%-1.7%) in the open approach, and 0.3% (n=5; 95% confidence interval, 0.3%-0.6%) in the minimally invasive approach (P=.02). The incidence rates of venous thromboembolism among the 1999 patients with malignancy were 0.9% (n=18; 95% confidence interval, 0.5%-1.4%) overall, 1.4% (n=15; 95% confidence interval, 0.7%-2.2%) in the open approach, and 0.3% (n=3; 95% confidence interval, 0.1%-0.9%) in the minimally invasive approach. The incidence rates of venous thromboembolism among the 1165 patients with benign disease were 0.3% (n=3; 95% confidence interval, 0.1%-0.7%) overall, 0.3% (n=1; 95% confidence interval, 0.0%-1.7%) in the open approach, and 0.2% (n=2; 95% confidence interval, 0.0%-0.9%) in the minimally invasive approach. The rate of venous thromboembolism among patients undergoing laparotomy and minimally invasive surgery on an Enhanced Recovery After Surgery pathway was ≤1%. This study established a benchmark for the rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center.

Enhanced Recovery After Surgery (ERAS) practices in minimally invasive gynecologic surgery: A national survey

Introduction Enhanced Recovery After Surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, and subsequently reduce postoperative complications and recovery time. The objectives of this study were to assess the Canadian application of and adherence to ERAS protocols during minimally invasive gynecologic surgery, and identify barriers to ERAS uptake.

The deep inferior epigastric perforator flap: where we started and where we are now.

The deep inferior epigastric perforator (DIEP) flap has been performed since the early 1990s. This represented a significant advancement from the prior autologous options that required removal of all or a portion of various muscle groups. Over the years numerous advancements and modifications have been made to DIEP flap reconstruction that have further facilitated our ability to provide this option following mastectomy. Advancements with preoperative preparation, intraoperative techniques, and postoperative management have served to determine eligibility for DIEP flap reconstruction, improve surgical outcomes, reduce complications, reduce surgical operative time, and facilitate postoperative monitoring. Preoperative advancements have included vascular imaging to identify perforators. Intraoperative advancements have included using the internal mammary perforators as the optimal recipient vessels rather than the thoracodorsal, having a two-team approach with microsurgical reconstruction to reduce operative time and improve outcomes when compared to the single surgeon strategy, using a venous coupler rather than hand sewing the anastomosis, using tissue perfusion technology to determine the perfusion limits within the flap. Postoperative advancements include the use of technology to optimally monitor flaps as well as the use of using enhanced recovery after surgery pathways to improve the postoperative experience and promote early and safe discharge from the hospital. This manuscript will review the evolution of the DIEP flap as it relates to comparing our earlier techniques and strategies compared to our current techniques and strategies following mastectomy and breast reconstruction.

Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data

BackgroundThe National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target. ObjectiveTo investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England. Design, setting, and participantsThis was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022. Outcome measurements and statistical analysisDay-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition. Results and limitationsOf 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013–2014 to 31% in 2021–2022. The move from inpatient stays to day-case surgery between 2013–2014 and 2021–2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021–2022 would be 217 599 kg CO2 equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways. ConclusionsOur study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings. Patient summaryIn this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013–2014 and 2021–2022 has saved 2.9 million kg CO2 equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021–2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

Evaluating the efficacy and safety of simple combination of analgesics with and without low dose opioid for perioperative analgesia, hemodynamic and recovery profile in various surgeries posted under general anaesthesia: a prospective randomised controlled study

Background: Multimodal analgesia is an emerging technique.It has been consistently demonstrated to minimise opioid consumption, related side effects and vital component of enhanced recovery after surgery pathways. The current study presents use of combination of readily available medication as a part of multimodal analgesia. Balanced anaesthesia with multimodal analgesia is harmonious use of combination of agents to produce desired effects with minimal side effects of individual agents. Methods: This study was done in a tertiary health care centre, Government General Hospital, Kakinada over a duration of two months from August 2022 to September 2022. 60 adult patients of either sex of physical status ASA grade 1and 2 undergoing elective surgery under general anaesthesia were randomly allocated into Group A and Group B of 30 patients. Group 1: received Inj. Lignocaine+Inj. Paracetamol+Inj. Magnesium sulphate+Inj. Fentanyl. Group 2:received Inj. Lignocaine+Inj. Paracetamol+Inj. Magnesium sulphate+Normal saline (control group) as premedication for perioperative analgesia. Results: All patients were hemodynamically stable for first 30 minutes period of observation in Group A compared to Group B. There is clinically and statistically significant difference in the duration of analgesia in Group A compared to Group B. There is no statistically significant difference in the Numerical Rating Scale (NRS) for pain in both the groups. Conclusions: This study concluded that simple analgesia combination of multimodal analgesia regimen comprising of Inj. Lignocaine, Inj. Paracetamol and Inj. Magnesium sulphate produces safe and effective analgesia with good recovery profiles and no adverse opioid related side effects for ASA 1 and 2 patients posted under general anaesthesia.

A Medicoeconomic Evaluation of a Telehealth Platform for Elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial

The number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients' pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery. The objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways. This study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21% reduction in postoperative complications with a power of 90%. This study has been approved by the ethics board of Centre hospitalier de l'Université de Montréal (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis. Results of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways. We believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care. ClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632. DERR1-10.2196/44006.

Bilateral transversus abdominis plane and rectus sheath blocks with liposomal bupivacaine for patients undergoing robotic prostatectomy.

As robotic prostatectomy surgery becomes more prevalent, it is important to identify any regional techniques to optimize patient's recovery. We evaluated the effectiveness of bilateral transversus abdominis plane (TAP) and rectus sheath (RS) blocks with liposomal bupivacaine. We hypothesized that these blocks would reduce perioperative opioid use and pain scores. A retrospective cohort of patients from May 2018 and May 2021 at a single large VA hospital were studied. We compared those not receiving a nerve block against those receiving the TAP and RS as part of an Enhanced Recovery After Surgery (ERAS) pathway starting in May 2019. The primary outcome was post-operative opioid use. Secondary outcomes were post-operative pain scores and hospital length of stay. One hundred and thirty-four patients were included in the final analysis. Eighty-one patients did not receive a block and fifty-three patients did receive a block. No difference existed between the groups in regard to median oral morphine equivalents (mg) used in PACU or any post-operative day. No difference existed in median opioid usage (mg) or pain scores between the two groups on any post-operative day. There was no difference in temporal association of median pain scores or narcotic usage between the two groups. Bilateral TAP and RS with liposomal bupivacaine did not significantly decrease post-operative opioid use, improve pain scores, or decrease hospital length of stay for patients undergoing robotic prostatectomy. Further studies need to be done to evaluate the effect of these blocks with liposomal bupivacaine.

Clinical outcome of ambulatory anterior cruciate ligament reconstruction compared with the standard in-patient surgery

Purpose There is a current trend toward performing anterior cruciate ligament reconstruction (ACLR) as a day surgery procedure. However, the full evaluation of this process compared with the traditional inpatient ACLR was not accomplished particularly from the perspective of patient satisfaction, pain improvement, and final outcome. Furthermore, several centers described refusal of patients to pass through the day surgery protocol with more preference to admission. The aim of this study is the evaluation of early/late results of short-term hospital stay following arthroscopic ACLR with regard to patient recovery, complications, patient satisfaction, and return to daily activities through our algorithm. Patients and methods Through a prospective randomized study, 284 patients were operated for ACLR through two pathways; G1 is the day surgery pathway and G2 is the traditional inpatient pathway. Patients were evaluated postoperatively for pain severity, satisfaction, the need for additional analgesia, any readmission, complications, and final outcome. Results Patients in both groups showed similar pain and satisfaction levels with no difference regarding the amount of extra-analgesia needed and with no readmission from the day surgery group. However, seven patients were recorded as reattending the hospital seeking for pain medication which was given in ER and the patient was satisfied to return home with no need for readmission. Conclusions In conclusion, day surgery can be considered as the protocol of choice for patients undergoing ACLR with no difference from the former standard in-patient ACLR.