Julie K. Thacker

Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

BackgroundThis review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.MethodsStudies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.ResultsFor most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate).ConclusionsBased on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Reduced Length of Hospital Stay in Colorectal Surgery after Implementation of an Enhanced Recovery Protocol

BACKGROUND:Enhanced recovery after surgery (ERAS) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilization and feeding after surgery. We investigated the feasibility, clinical effectiveness, and cost savings of an ERAS program at a major U. S. teaching hospital. METHODS:Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, before and after implementation of an ERAS protocol. Data collected included patient demographics, operative, and perioperative surgical and anesthesia data, need for analgesics, complications, inpatient medical costs, and 30-day readmission rates. RESULTS:There were 99 patients in the traditional care group, and 142 in the ERAS group. The median length of stay (LOS) was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). The reduction in LOS was significant for both open procedures (median 6 vs 7 days, P = 0.01), and laparoscopic procedures (4 vs 6 days, P < 0.0001). ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03). Readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02). DISCUSSION:Implementation of an enhanced recovery protocol for colorectal surgery at a tertiary medical center was associated with a significantly reduced LOS and incidence of urinary tract infection. This is consistent with that of other studies in the literature and suggests that enhanced recovery programs could be implemented successfully and should be considered in U.S. hospitals.

The Preventive Surgical Site Infection Bundle in Colorectal Surgery An Effective Approach to Surgical Site Infection Reduction and Health Care Cost Savings

IMPORTANCE Surgical site infections (SSIs) in colorectal surgery are associated with increased morbidity and health care costs. OBJECTIVE To determine the effect of a preventive SSI bundle (hereafter bundle) on SSI rates and costs in colorectal surgery. DESIGN Retrospective study of institutional clinical and cost data. The study period was January 1, 2008, to December 31, 2012, and outcomes were assessed and compared before and after implementation of the bundle on July 1, 2011. SETTING AND PARTICIPANTS Academic tertiary referral center among 559 patients who underwent major elective colorectal surgery. MAIN OUTCOMES AND MEASURES The primary outcome was the rate of superficial SSIs before and after implementation of the bundle. Secondary outcomes included deep SSIs, organ-space SSIs, wound disruption, postoperative sepsis, length of stay, 30-day readmission, and variable direct costs of the index admission. RESULTS Of 559 patients in the study, 346 (61.9%) and 213 (38.1%) underwent their operation before and after implementation of the bundle, respectively. Groups were matched on their propensity to be treated with the bundle to account for significant differences in the preimplementation and postimplementation characteristics. Comparison of the matched groups revealed that implementation of the bundle was associated with reduced superficial SSIs (19.3% vs 5.7%, P < .001) and postoperative sepsis (8.5% vs 2.4%, P = .009). No significant difference was observed in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs between the matched groups. However, in a subgroup analysis of the postbundle period, superficial SSI occurrence was associated with a 35.5% increase in variable direct costs (

Perioperative Fluid Utilization Variability and Association With Outcomes: Considerations for Enhanced Recovery Efforts in Sample US Surgical Populations.

13,253 vs

A prospective comparison of a noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients

9779, P = .001) and a 71.7% increase in length of stay (7.9 vs 4.6 days, P < .001). CONCLUSIONS AND RELEVANCE The preventive SSI bundle was associated with a substantial reduction in SSIs after colorectal surgery. The increased costs associated with SSIs support that the bundle represents an effective approach to reduce health care costs.

Worse Outcomes in Patients Undergoing Urgent Surgery for Left-Sided Diverticulitis Admitted on Weekends vs Weekdays: A Population-Based Study of 31 832 Patients

Objectives:To study current perioperative fluid administration and associated outcomes in common surgical cohorts in the United States. Background:An element of enhanced recovery care protocols, optimized perioperative fluid administration may be associated with improved outcomes; however, there is currently no consensus in the United States on fluid use or the effects on outcomes of this use. Methods:The study included all inpatients receiving colon, rectal, or primary hip or knee surgery, 18 years of age or older, who were discharged from a hospital between January 1, 2008 and June, 30 2012 in the Premier Research Database. Patient outcomes and intravenous fluid utilization on the day of surgery were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low day-of-surgery fluids with the likelihood of increased hospital length of stay (LOS), total costs, or postoperative ileus. Results:The study showed significant associations between high fluid volume given on the day of surgery with both increased LOS (odds ratio 1.10–1.40) and increased total costs (odds ratio 1.10–1.50). High fluid utilization was associated with increased presence of postoperative ileus for both rectal and colon surgery patients. Low fluid utilization was also associated with worse outcomes. Conclusions:According to results from this review of current practice in US hospitals, fluid optimization would likely lead to decreased variability and improved outcomes.

Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis

BACKGROUND:Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS:One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient’s stroke volume was optimized using 250-mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS:Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were −0.96 to +1.95 days (P = 0.5016). CONCLUSIONS:The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.

Detection of intestinal dysplasia using angle-resolved low coherence interferometry

HYPOTHESIS Among patients undergoing urgent surgery for left-sided diverticulitis, those admitted on weekends vs weekdays have higher rates of Hartmann procedure and adverse outcomes. DESIGN Analysis of data from the Nationwide Inpatient Sample between January 2002 and December 2008. Unadjusted and risk-adjusted generalized linear regression models were used. SETTING Academic research. PATIENTS Data on patients undergoing urgent surgery for acute diverticulitis. MAIN OUTCOME MEASURES Rates of Hartmann procedure vs primary anastomosis, complications, length of hospital stay, and total hospital charges. RESULTS In total, 31 832 patients were included; 7066 (22.2%) were admitted on weekends, and 24 766 (77.8%) were admitted on weekdays. The mean (SD) age of patients was 60.8 (15.3) years, and 16 830 (52.9%) were female. A Hartmann procedure was performed in 4580 patients (64.8%) admitted on weekends compared with 13 351 patients (53.9%) admitted on weekdays (risk-adjusted odds ratio [OR], 1.57; P < .001). In risk-adjusted analyses, patients admitted on weekends had significantly higher risk for any postoperative complication (OR, 1.10; P = .005) and nonroutine hospital discharge (OR, 1.33; P < .001) compared with patients admitted on weekdays, as well as a median length of hospital stay that was 0.5 days longer and median total hospital charges that were

Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs

3734 higher (P < .001 for both). CONCLUSIONS Patients undergoing urgent surgery for left-sided diverticulitis who are admitted on a weekend have a higher risk for undergoing a Hartmann procedure and worse short-term outcomes compared with patients who are admitted on a weekday. Further research is warranted to investigate possible underlying mechanisms and to develop strategies for reducing this substantial weekend effect.