Catherine Blanc

Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery.

Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost‐effectiveness of enhanced recovery implementation.

Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.

OBJECTIVEnTo compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery.nnnBACKGROUNDnEDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious.nnnMETHODSnA total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle.nnnRESULTSnFinal analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted.nnnCONCLUSIONSnEpidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.

Enhanced Recovery Pathway for Urgent Colectomy

AbstractBackgroundEnhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway.nMethodsIn a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome.ResultsPatients (Nxa0=xa028) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (Nxa0=xa063). Overall compliance with the protocol was 57xa0% for the urgent compared with 77xa0% for the elective procedures (pxa0=xa00.006). The pre-operative compliance was 64 versus 96xa0% (pxa0<xa00.001), the intra-operative compliance was 77 versus 86xa0% (pxa0=xa00.145), and the post-operative compliance was 49 versus 67xa0% (pxa0=xa00.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64xa0%) and 32 elective patients (51xa0%) developed postoperative complications (pxa0=xa00.261). Median postoperative length of stay was 8xa0days in the urgent setting compared with 5xa0days in the elective setting (pxa0=xa00.006).ConclusionsMany of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting.

Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery

BackgroundEnhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as “aggressive” care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients.MethodsSince June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (<70xa0years) and 202 older patients (≥70xa0years). Outcomes were adherence to the ERAS pathway, functional recovery, postoperative complications, and hospital stay.ResultsOlder patients had significantly more diabetes, malignancies, cardiac, and respiratory co-morbidities; both groups underwent similar surgical procedures. Overall adherence to the ERAS pathway was in median 78xa0% in younger and 74xa0% in older patients (Pxa0=xa00.86). In older patients, urinary drains were kept longer (Pxa0=xa00.001), and oral fluid intake was reduced from day 0 to day 3 (Pxa0<xa00.001). There were no differences in mobilization and intake of nutritional supplements. Postoperative complications were similar for both comparative groups (51.5 vs. 46.6xa0%, Pxa0=xa00.32). Median length of stay was 7xa0days (IQR 5–13) in older patients vs. 6xa0days (IQR 4–10) in the younger group (Pxa0=xa00.001).ConclusionAdherence to the ERAS pathway was equally high in older patients. Despite more co-morbidities, older patients did not experience more complications. Recovery was similar and hospital stay was only 1xa0day longer than in younger patients. ERAS pathway is of value for all patients and does not need any adaptation for the elderly.

Recurrent cytomegalovirus disease, visceral leishmaniosis, and Legionella pneumonia after liver transplantation: a case report

PurposeRecurrent cytomegalovirus (CMV) disease is a frequent complication of liver transplantation. Visceral leishmaniosis in a transplant recipient is, on the other hand, extremely rare and only two cases of kala-azar have been described after liver transplantation. Immunosuppressed patients are known to be at risk of Legionella infection and the relationship between infection with this organism and hospital water supplies has been well described. These three diseases carry a high mortality rate. Our report examines the potential relationship between these complications.Clinical featuresWe describe the case of a liver transplant recipient who presented the three complications successively and survived. After reviewing the literature, we explore hypotheses linking these infections and discuss treatment strategies.ConclusionsIn the patient described, infection with leishmania probably occurred months prior to the clinical presentation, a delay that matches the incubation period of kala-azar. The simultaneous onset of leishmaniosis and of a high CMV viremia may have been a coincidence. However, CMV infection has been shown to be an independent predictor of invasive fungal infection in liver transplant recipients. CMV does indeed have a suppressive effect on the humoral and cellular immune responsein vitro as well asin vivo. The clinical manifestations of leishmaniosis may, therefore, have been precipitated in this patient by the additive immunosuppressive effect of antirejection drugs and CMV.RésuméObjectifL’linfection récurrente au cytomégalovirus (CMV) est une complication fréquente de la transplantation hépatique. La leishmaniose viscérale chez un receveur d’organe est, par contre, extrêmement rare et on ne rapporte que deux cas de kalaazar à la suite d’une greffe de foie. Les patients immunodéprimés sont à risque d’infections à Légionella et la relation entre cet organisme et l’alimentation en eau des hôpitaux a été bien décrite. Ces trois maladies présentent un taux de mortalité élevée. Nous étudions ici la relation possible entre ces complications.Éléments cliniquesNous décrivons le cas d’un patient greffé du foie qui a présenté successivement les trois complications et a survécu. Après avoir passé en revue les publications, nous explorons des hypothèses pouvant relier ces infections et discutons des traitements possibles.ConclusionChez ce patient, l’infection à Leishmania est probablement survenue plusieurs mois avant les manifestations cliniques, ce qui correspond à la période d’incubation du kalaazar. La survenue simultanée d’une leishmaniose et d’une importante virémie au CMV pourrait n’être qu’une coïncidence. Cependant, l’infection au CMV s’est révélée un prédicteur indépendant d’infection fongique invasive chez les receveurs d’un foie. Le CMV a certainement un effet inhibiteur sur la réponse immunitaire humorale et cellulaire, in vitro aussi bien qu’in vivo. Les manifestations cliniques de la leishmaniose peuvent donc avoir été précipitées par l’effet immunodépresseur supplémentaire des médicaments antirejet et du CMV.

Cost–Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery

BackgroundEnhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.MethodsA dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed.ResultsSeventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (nxa0=xa018 ERAS, nxa0=xa09 pre-ERAS, pxa0=xa00.010). Overall postoperative complications were observed in 36 (49xa0%) and 64 patients (64xa0%) in the ERAS and pre-ERAS groups, respectively (pxa0=xa00.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10xa0days, pxa0=xa00.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (pxa0=xa00.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.ConclusionsERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.

The impact of an enhanced recovery pathway on nursing workload: A retrospective cohort study ☆

BACKGROUND & AIMSnThe importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfillment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery.nnnMETHODSnThe program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol.nnnRESULTSnThe study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001).nnnCONCLUSIONSnNursing workload is--against a common belief--decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!

Implementation of Enhanced Recovery (ERAS) in Colorectal Surgery Has a Positive Impact on Non-ERAS Liver Surgery Patients.

BackgroundEnhanced recovery after surgery (ERAS) reduces complications and hospital stay in colorectal surgery. Thereafter, ERAS principles were extended to liver surgery. Previous implementation of an ERAS program in colorectal surgery may influence patients undergoing liver surgery in a non-ERAS setting, on the same ward. This study aimed to test this hypothesis.MethodsRetrospective analysis based on prospective data of the adherence to the institutional ERAS-liver protocol (compliance) in three cohorts of consecutive patients undergoing elective liver surgery, between June 2010 and July 2014: before any ERAS implementation (pre-ERAS nxa0=xa050), after implementation of ERAS in colorectal (intermediate nxa0=xa050), and after implementation of ERAS in liver surgery (ERAS-liver nxa0=xa074). Outcomes were functional recovery, postoperative complications, hospital stay, and readmissions.ResultsThe three groups were comparable for demographics; laparoscopy was more frequent in ERAS-liver (pxa0=xa00.009). Compliance with the enhanced recovery protocol increased along the three periods (pre-ERAS, intermediate, and ERAS-liver), regardless of the perioperative phase (pre-, intra-, or postoperative). ERAS-liver group displayed the highest overall compliance rate with 73.8xa0%, compared to 39.9 and 57.4xa0% for pre-ERAS and intermediate groups (pxa0=xa00.072/0.056). Overall complications were unchanged (pxa0=xa00.185), whereas intermediate and ERAS-liver groups showed decreased major complications (pxa0=xa00.034). Consistently, hospital stay was reduced by 2xa0days (pxa0=xa00.005) without increased readmissions (pxa0=xa00.158).ConclusionsThe previous implementation of an ERAS protocol in colorectal surgery may induce a positive impact on patients undergoing non-ERAS-liver surgery on the same ward. These results suggest that ERAS is safely applicable in liver surgery and associated with benefits.

Enhanced recovery implementation in colorectal surgery—temporary or persistent improvement?

PurposeEnhanced recovery after surgery (ERAS) implementation has proven to reduce complication rate and length of hospital stay. Little is known about the sustainability of these results over time. The study aim was to assess the application of ERAS pathway over the first 4xa0years after initial implementation.MethodsThis retrospective study analyzed data collected prospectively from 482 consecutive elective colorectal patients operated in 2011 during the ERAS implementation process (nxa0=xa066), and after initial implementation in 2012 (nxa0=xa0136), 2013 (nxa0=xa0152), and 2014 (nxa0=xa0128). Auditing ERAS was appraised from different perspectives: adherence with the ERAS protocol, clinical outcomes, and functional recovery. Patients were compared by year.ResultsThe groups were similar in terms of demographics and surgical strategies. Length of stay remained stable at 7xa0days without significant variation over time (pxa0=xa00.741). The 30-day complications and readmission rates were not statistically different (respectively pxa0=xa00.068 and pxa0=xa00.639). There was also no difference in functional recovery, more particularly, first flatus occurred at day 2 (pxa0=xa00.177), pain was adequately controlled with oral analgesics at day 2 (pxa0=xa00.111), and patients were mobilized more than 4xa0h the first postoperative day in more than 60xa0% of cases (pxa0=xa00.343). Overall adherence with the ERAS pathway was 73xa0% during implementation and, respectively, 73 and 77xa0% for 2012 and 2013 after initial implementation (pxa0=xa00.614). A significant decrease between 2013 (77xa0%) and 2014 (73xa0%) was observed (pxa0=xa00.032).ConclusionsApplication of the institutional ERAS pathway could be maintained in the first 4xa0years after implementation leading to sustained improved functional recovery and clinical outcome.

Postoperative urinary retention in colorectal surgery within an enhanced recovery pathway

BACKGROUNDnEnhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection (UTI). The aim of this study was to identify risk factors for urinary retention (UR).nnnMETHODSnThis retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates.nnnRESULTSnThe study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; Pxa0=xa00.045) and postoperative thoracic epidural analgesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, Pxa0=xa00.024) and gained more weight (2.8xa0±xa02.5xa0kg versus 1.6xa0±3xa0kg on day 1, Pxa0=xa00.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1xa0±xa02.5 versus 2.2xa0±xa02.4, Pxa0=xa00.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, Pxa0=xa00.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR (Pxa0=xa00.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR (Pxa0=xa00.991).nnnCONCLUSIONSnMale gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery.