Lawrence Lee

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

Background:The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods:A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results:Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. −21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion:Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

Systematic review of outcomes used to evaluate enhanced recovery after surgery

Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies.

A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery.

Objective:To perform a systematic review of economic evaluations of enhanced recovery pathways (ERP) for colorectal surgery. Background:Although there is extensive literature investigating the clinical effectiveness of ERP, little is known regarding its cost-effectiveness. Methods:A systematic literature search identified all relevant articles published between 1997 and 2012 that performed an economic evaluation of ERP for colorectal surgery. Studies were included only if their ERP included all 5 of the key components (patient information, preservation of GI function, minimization of organ dysfunction, active pain control, and promotion of patient autonomy). Quality assessment was performed using the Consensus on Health Economic Criteria instrument (scored 0–19; high quality ≥ 12). Incremental cost-effectiveness ratios were calculated if sufficient data were provided, using difference in length of stay and overall complication rates as effectiveness measures. Results:Of a total of 263 unique records identified (253 from databases and 10 from other sources), 10 studies met our inclusion criteria and were included for full qualitative synthesis. Overall quality was poor (mean quality 7.8). Eight reported lower costs for ERP. The majority (8 of 10) of studies were performed from an institutional perspective and therefore did not include costs related to changes in productivity and other indirect costs (eg, caregiver burden). Five studies provided enough information to calculate ICERs, of which ERP was dominant (less costly and more effective) in all cases for reduction in length of stay and was dominant or potentially cost-effective in 4 and questionable (no difference in costs nor effectiveness) in 1 for reduction in overall complications. Conclusions:The quality of the current evidence is limited but tends to support the cost-effectiveness of ERP. There is need for well-designed trials to determine the cost-effectiveness of ERP from both the institutional and societal perspectives.

An enhanced recovery pathway decreases duration of stay after esophagectomy.

PURPOSE Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy. METHODS Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values [interquartile range]. RESULTS We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 [7-17] vs 10 [9-17] days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%). CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.

What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways

PurposeThe purpose of this narrative review is to provide a framework from which to measure the outcomes of Enhanced Recovery After Surgery (ERAS) programs.Principle findingsWe define the outcomes of recovery from the perspective of different stakeholders and time frames. There is no single definition of recovery. There are overlapping phases of recovery which are of particular interest to different stakeholders (surgeons, anesthesiologists, nurses, patients and their caregivers), and the primary outcome of interest may vary depending on the phase and the perspective. In the earliest phase (from the end of the surgery to discharge from the postanesthesia care unit [PACU]), biologic and physiologic outcomes are emphasized. In the intermediate phase (from PACU to discharge from the hospital), symptoms related to pain and gastrointestinal function as well as basic activities are important. Studies of ERAS pathways have reported clinical outcomes and symptoms, including complications, hospital stay, mobilization, and gastrointestinal function, largely during hospitalization. Nevertheless, patients define recovery as return to normal functioning, a process that occurs over weeks to months (late phase). Outcomes reflecting functional status (e.g., physical activity, activities of daily living) and overall health (e.g., quality of life) are important in this phase. To date, few studies reporting the effectiveness of ERAS pathways compared with conventional care have included functional status or quality-of-life outcomes, and there is little information about recovery after discharge from hospital.ConclusionRecovery after surgery is a complex construct. Different outcomes are important at different phases along the recovery trajectory. Measures for quantifying recovery in hospital and after discharge are available. A consensus-based core set of outcomes with input from multiple stakeholders would facilitate research reporting.RésuméObjectifL’objectif de cette synthèse narrative est de fournir un cadre à partir duquel les aboutissements des programmes de récupération rapide après une chirurgie (RRAC) pourront être mesurés.Constatations principalesNous définissons les aboutissements de la récupération du point de vue des différents acteurs et selon des échelles de temps différentes. Il n’existe pas de définition unique de la récupération. Il y a des phases de convalescence qui se chevauchent et qui intéressent plus particulièrement des acteurs différents (chirurgiens, anesthésiologistes, infirmières, patients et leurs soignants) et l’aboutissement primaire d’intérêt peut varier en fonction de la phase et du point de vue de chacun. Dans la phase la plus précoce (de la fin de la chirurgie à la sortie de la salle de réveil), on insiste sur les paramètres biologiques et physiologiques. Au cours de la phase intermédiaire (de la salle de réveil au congé de l’hôpital), les symptômes liés à la douleur et à la fonction digestive, ainsi que les activités fondamentales sont importants. Les études des voies RRAC ont signalé les aboutissements cliniques et symptômes, y compris les complications, la durée de l’hospitalisation, la mobilisation et la fonction digestive, principalement au cours de l’hospitalisation. Les patients, cependant, définissent la récupération comme un retour à un fonctionnement normal, un processus qui survient en plusieurs semaines ou en plusieurs mois (phase tardive). Les aboutissements reflétant le statut fonctionnel (par exemple, l’activité physique, les activités de la vie quotidienne) et l’état de santé global (par exemple, la qualité de vie) sont importants au cours de cette phase. À ce jour, peu d’études présentant l’efficacité des voies RRAC comparées aux soins conventionnels ont inclus le statut fonctionnel ou la qualité de vie et on ne dispose que de peu d’information sur la récupération après le congé de l’hôpital.ConclusionLa récupération après chirurgie est un ensemble complexe. Divers aboutissements sont importants à différentes phases tout au long de la trajectoire vers la récupération. Il existe des mesures de quantification de la récupération à l’hôpital et après le congé donné au patient. Un ensemble central d’aboutissements basé sur un consensus bénéficiant de l’apport de multiples acteurs faciliterait la présentation des résultats d’études.

Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery.

Objective: To determine the cost-effectiveness of enhanced recovery pathways (ERPs) versus conventional care for patients undergoing elective colorectal surgery. Background: ERPs for colorectal surgery are clinically effective, but their cost-effectiveness is unknown. Methods: A multi-institutional prospective cohort cost-effectiveness analysis was performed. Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled. One center used an ERP, whereas the other did not. Postoperative outcomes were recorded up to 60 days. Total costs were reported in 2013 Canadian dollars. Effectiveness was measured using the SF-6D, a health utility measure validated for postoperative recovery. Uncertainty was expressed using bootstrapped estimates (10,000 repetitions). Results: A total of 180 patients were included (conventional care: n = 95; ERP: n = 95). There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group. Mean length of stay was shorter in the ERP group (6.5 vs 9.8 days; P = 0.017), but there were no differences in complications or readmissions. Patients in the ERP group returned to work quicker and had less caregiver burden. There was no difference in quality of life between the 2 groups. The cost of the ERP program was

Predicting Lymph Node Metastases in Early Esophageal Adenocarcinoma Using a Simple Scoring System

153 per patient. Overall societal costs were lower in the ERP group (mean difference = −2985; 95% confidence interval, −5753 to −373). The ERP had a greater than 99% probability of cost-effectiveness. The results were insensitive to a range of assumptions and subgroups. Conclusions: Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection.

Economic impact of an enhanced recovery pathway for oesophagectomy

BACKGROUND Endoscopic resection is an organ-sparing option for early esophageal adenocarcinoma, but should be used only in patients with a negligible risk of lymph node metastases (LNM). The objective was to develop a simple scoring system to predict LNM in T1 esophageal adenocarcinoma. STUDY DESIGN All primary esophagectomies performed for T1 esophageal adenocarcinoma without neoadjuvant therapy at 5 university institutions from 2000 to 2011 were analyzed. Patient and pathologic characteristics were compared between patients with LNM at the time of surgical resection and those without. Univariate and multivariate analyses were performed to establish a simple scoring system that estimated the risk of LNM, using variables from the final surgical pathology. RESULTS A total of 258 patients were included for analysis (mean age 65.2 years [SD 10.3 years], 88% male). The incidence of LNM was 7% (9 of 122) for T1a and 26% (35 of 136) for T1b. Tumor size (odds ratio [OR] 1.35 per cm, 95% CI 1.07 to 1.71) and lymphovascular invasion (OR 7.50, 95% CI 3.30 to 17.07) were the strongest independent predictors of LNM. A weighted scoring system was devised from the final multivariate model and included size (+1 point per cm), depth of invasion (+2 for T1b), differentiation (+3 for each step of dedifferentiation), and lymphovascular invasion (+6 if present). Total number of points estimated the probability of LNM (low risk [0 to 1 point], ≤ 2%; moderate risk [2 to 4 points], 3% to 6%; and high risk [5+ points], ≥ 7%). CONCLUSIONS We devised a simple scoring system that accurately estimates the risk of LNM to aid in decision-making in patients with T1 esophageal adenocarcinoma undergoing endoscopic resection.

The association of the distance walked in 6 min with pre- operative peak oxygen consumption and complications 1 month after colorectal resection*

Data are lacking to support the cost‐effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy.

Systematic review of the influence of enhanced recovery pathways in elective lung resection

We measured the distance 112 patients walked in 6 min, as well as their peak oxygen consumption pedalling a bicycle, week before scheduled resection of benign or malignant colorectal disease. The distance walked correlated with peak oxygen consumption, the former ‘accounting’ for about half the variation in the latter, r2 0.52 (95% CI 0.38–0.64), p < 0.0001. In the first postoperative month, 42/112 patients experienced a complication. In multivariate analysis, complications were less likely with longer walking distances and increasing age: the odds ratio (95% CI) reduced to 0.995 (0.990–0.999) for each metre distance, and to 0.96 (0.93–0.99) with each year of age, p = 0.025 and p = 0.018, respectively. The distance walked in 6 min before surgery can provide prognostic information when cardiopulmonary exercise testing is unavailable.