Gabriele Baldini

An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery

BackgroundEnhanced perioperative care programs have been developed in order to attenuate the impact of surgical stress on organ dysfunction, thereby accelerating hospital discharge and reducing morbidity. The implementation of a fast-track program for laparoscopic colorectal surgery is reported.MethodsWe report on a series of patients who entered a coordinated program based on preoperative patient education and counseling, a laparoscopic approach, provision of postoperative epidural analgesia, early food intake and mobilization, and structured surgical and nursing care practices. The program was introduced in September 2006 and adapted to our institutional needs. Outcome measures included length of hospital stay, return of bowel function, incidences of postoperative complications, and rate of readmission to hospital.ResultsTwenty-five patients were selected by the surgeons for the accelerated laparoscopic colorectal pathway. The median duration of hospital stay was 3 (95% confidence interval, 3–4) days. Sixteen patients (64%) were discharged from hospital on day 3. Nine patients failed the pathway for various reasons (social indications, poor pain relief, wound infection, anemia, urinary retention) and were discharged later (six patients on day 4, two patients on day 5, and one patient on day 6). Times to recover bowel function and to resume a full diet were all within the first 36xa0hr from time of surgery. There were two readmissions.ConclusionThis early clinical experience demonstrates the feasibility of a fast-track program for colonic surgery and the requirement for an integrated multidisciplinary approach to perioperative care.RésuméContexteDes programmes de soins périopératoires améliorés ont été élaborés afin d’atténuer l’impact du stress chirurgical sur la défaillance systémique, ce qui a permis d’accélérer le congé de l’hôpital et de réduire la morbidité. La mise en œuvre d’un programme accéléré pour la chirurgie colorectale par laparoscopie est décrite ici.MéthodeNous présentons une série de patients ayant participé à un programme coordonné et décrivons la formation et la consultation préopératoire des patients, l’approche par laparoscopie, la prestation d’une analgésie péridurale postopératoire, l’absorption de nourriture et la mobilisation précoce, et les pratiques structurées de soins chirurgicaux et infirmiers. Le programme a été mis en place en septembre 2006 et adapté pour répondre aux besoins de notre institution. Nous avons mesuré la durée du séjour à l’hôpital, la restauration de la fonction intestinale, l’incidence de complications postopératoires et le taux de réadmission à l’hôpital.RésultatsVingt-cinq patients ont été sélectionnés par les chirurgiens pour subir une intervention accélérée par la voie colorectale par laparoscopie. La durée médiane du séjour à l’hôpital était de 3 jours (IC 95xa0%, 3-4). Seize patients (64xa0%) ont quitté l’hôpital au jour 3, la voie laparoscopique a échoué pour diverses raisons chez neuf patients (indications sociales, mauvais soulagement de la douleur, infection de plaie, anémie, rétention urinaire) qui ont reçu leur congé plus tard (six patients le quatrième jour, deux patients le cinquième jour, et un le sixième jour). La restauration de la fonction intestinale et le retour à un régime alimentaire normal ont eu lieu pour tous les patients dans les 36 premières heures suivant la chirurgie. Il y a eu deux réadmissions.ConclusionCette expérience clinique précoce démontre la faisabilité d’un programme accéléré pour la chirurgie du colon et le besoin d’une approche pluridisciplinaire intégrée aux soins périopératoires.

Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial

BACKGROUNDnThis study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection.nnnMETHODSnFifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay.nnnRESULTSnPostoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P<0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P<0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay).nnnCONCLUSIONSnWhen ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.

Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program

IntroductionGuidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection.MethodsProspectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0–100). Regression analyses were adjusted for potential confounders.ResultsA total of 347 patients were included in the study. Median primary LOS was 4xa0days (IQR 3–7). Patients were adherent to median 18 (IQR 16–20) elements. A total of 156 (45xa0%) patients had successful recovery. Morbidity occurred in 175 (50xa0%) patients with median CCI 8.6 (IQR 0–22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, pxa0<xa00.001), LOS (11xa0% reduction for every additional element, pxa0<xa00.001), 30-day postoperative morbidity (OR 0.78, pxa0<xa00.001), and the CCI (17xa0% reduction, pxa0<xa00.001). Laparoscopy (OR 4.32, pxa0<xa00.001), early mobilization out of bed (OR 2.25, pxa0=xa00.021), and early termination of IV fluid infusion (OR 2.00, pxa0=xa00.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity.ConclusionsIncreased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.

Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery

Intraoperative goal‐directed therapy (GDT) was introduced to titrate intravenous fluids, with or without inotropic drugs, based on objective measures of hypovolaemia and cardiac output measurements to improve organ perfusion. This meta‐analysis aimed to determine the effect of GDT on the recovery of bowel function after abdominal surgery.

Optimal Analgesia During Major Open and Laparoscopic Abdominal Surgery

Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72xa0hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.

Anesthesia for Colorectal Surgery

Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.

Impact of a bladder scan protocol on discharge efficiency within a care pathway for ambulatory inguinal herniorraphy

AbstractBackgroundnPostoperative urinary retention (POUR) is a common complication of ambulatory inguinal herniorraphy, with an incidence reaching 38xa0%, and many surgeons require patients to void before discharge. This study aimed to assess whether the implementation of a bladder scan-based voiding protocol reduces the time until discharge after ambulatory inguinal herniorraphy without increasing the rate of POUR.MethodsAs part of a perioperative care pathway, a protocol was implemented to standardize decision making after elective inguinal hernia repair (February 2012). Patients were assessed with a bladder scan, and those with <600xa0mL of urine were discharged home, whereas those with more than 600xa0mL of urine had an in-and-out catheterization before discharge. The patients received written information about urinary symptoms and instructions to present to the emergency department if they were unable to void at home. An audit of scheduled outpatient inguinal hernia repairs between October 2011 and July 2012 was performed. Comparisons were made using the t test, Fisher’s exact test, and Wilcoxon rank sum test where appropriate. Statistical significance was defined a priori as a p value lower than 0.05.ResultsDuring the study period, 124 patients underwent hernia repair: 60 before and 64 after implementation of the protocol. The findings showed no significant differences in patient characteristics, laparoscopic approach (35 vs. 33xa0%; pxa0=xa00.80), proportion receiving general anesthesia (70 vs. 73xa0%; pxa0=xa00.67), or amount of intravenous fluids given (793 vs. 663xa0mL; pxa0=xa00.07). The proportion of patients voiding before discharge was higher after protocol implementation (73 vs. 89xa0%; pxa0=xa00.02). The protocol had no impact on median time to discharge (190 vs. 205xa0min; pxa0=xa00.60). Only one patient in each group presented to the emergency department with POUR (2xa0%).ConclusionAfter ambulatory inguinal herniorraphy, implementation of a bladder scan-based voiding protocol did not result in earlier discharge. The incidence of POUR was lower than reported in the literature.

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.

The long-term prognostic impact of sentinel lymph node biopsy in patients with primary cutaneous melanoma: a prospective study with 10-year follow-up

Purpose Sentinel lymph node (SLN) biopsy (SLNB) is widely accepted for staging of melanoma patients. It has been shown that clinico-pathological features such as Breslow thickness, ulceration, age, and sex are better predictors of relapse and survival than SLN status alone. The aims of this study were to evaluate the long-term (10-year) prognostic impact of SLNB and to determine predictive factors associated with SLN metastasis, relapse, and melanoma specific mortality (MSM). Methods This was a prospective observational study on 289 consecutive patients with primary cutaneous melanoma who underwent SLNB from January 2000 to December 2007, and followed until January 2014, at an Italian academic hospital. Results SLN was positive in 64 patients (22.1%). The median follow-up was 116 months (79–147 months). Ten-year disease-free survival and melanoma specific survival were poor in patients with positive SLN (58.7% and 66.4%, respectively). Only the increasing Breslow thickness resulted independently associated to an increased risk of SLN metastasis. Cox regression analysis showed that a Breslow thickness >2 mm was an independent predictor of relapse, and male sex and Breslow thickness >2 mm was a predictor of MSM. At 10 years, SLN metastasis was not significantly associated to either relapse or MSM. Conclusion After the fifth year of follow-up, SLN metastasis is not an independent predictive factor of relapse or mortality which are mainly influenced by the characteristics of the primary tumor and of the patient. Patients with a Breslow thickness >2 mm regardless of the SLN status should be considered at high risk for 10-year relapse and mortality.

Choosing Analgesia to Facilitate Recovery

Surgical incision and manipulation of tissues lead to cell disruption and activation of humoral and cell-mediated inflammatory responses. A variety of intracellular chemical mediators including potassium, adenosine, prostanoids, bradykinin, nerve growth factors, cytokines, and chemokines are released from the injured tissues, then activate and sensitize peripheral nociceptors such as Aδ and c-fibers to mechanical stimuli (primary hyperalgesia). These pro-inflammatory substances together with the release of substance P and calcitonin gene-related peptide also sensitize silent Aδ nociceptors in the adjacent noninjured tissues (secondary hyperalgesia). Repeated and prolonged stimulation of peripheral nociceptors in the injured area and in the surrounding noninjured tissues leads to an increased firing of neurons at the level of the dorsal horn of the spinal cord, mediated by the activation of N-methyl-d-aspartate (NMDA) receptors (central sensitization). Clinically these pathophysiologic changes manifest with hyperalgesia, allodynia in the area of the surgical incision, with or without late persistent postsurgical pain. Descending sympathetic inhibitory pathways also take an important role at the level of the spinal cord by modulating transmission of noxious inputs. Acute surgical pain can therefore be somatic, visceral, or neuropathic depending on the type of surgery and on the surgical approach. Response to nociception contributes to activate and potentiate the stress response associated with surgery.