Magdalena Pisarska

Enhanced recovery after surgery protocol in oesophageal cancer surgery: Systematic review and meta-analysis

Background Enhanced Recovery After Surgery (ERAS) protocol are well established in many surgical disciplines, leading to decrease in morbidity and length of hospital stay. These multi-modal protocols have been also introduced to oesophageal cancer surgery. This review aimed to evaluate current literature on ERAS in oesophageal cancer surgery and conduct a meta-analysis on primary and secondary outcomes. Methods MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. We analyzed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was overall morbidity. Secondary outcomes included length of hospital stay, specific complications, mortality and readmissions. Random effect meta-analyses were undertaken. Results Initial search yielded 1,064 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. A total of 2,042 patients were included in the analysis (1,058 ERAS group and 984 treated with traditional protocols). Analysis of overall morbidity as well as complication rate did not show any significant reduction. Non-surgical complications and pulmonary complications were significantly lower in the ERAS group, RR = 0.71 95% CI 0.62–0.80, p < 0.00001 and RR = 0.75, 95% CI 0.60–0.94, p = 0.01, respectively. Meta-analysis on length of stay presented significant reduction Mean difference = -3.55, 95% CI -4.41 to -2.69, p for effect<0.00001. Conclusions This systematic review with a meta-analysis on ERAS in oesophageal surgery indicates a reduction of non-surgical complications and no negative influence on overall morbidity. Moreover, a reduction in the length of hospital stay was presented.

Laparoscopic colorectal cancer surgery combined with enhanced recovery after surgery protocol (ERAS) reduces the negative impact of sarcopenia on short-term outcomes

INTRODUCTION Progressive skeletal muscle loss (sarcopenia) is a negative prognostic factor in patients treated for colorectal cancer. Nevertheless, the clinical impact of those changes in body composition has been analyzed only in patients undergoing open resections. The aim of the study was to assess whether laparoscopy may eliminate the deleterious prognostic impact of sarcopenia and whether the combination with enhanced recovery after surgery (ERAS) protocol may improve postoperative recovery also in sarcopenic patients. METHODS The study included 124 (73M/51F, mean age 65.9 years) patients undergoing elective laparoscopic colorectal resection for cancer. In all of them 16-item ERAS protocol was applied. The L3 skeletal muscle area identified on a preoperative CT scan was used to calculate skeletal muscle index and assess for sarcopenia and myosteatosis. The entire study group was divided into groups regarding the presence of sarcopenia or myosteatosis. The outcome measures were: length of hospital stay, complication rate and functional recovery parameters. RESULTS The prevalence of sarcopenia and myosteatosis was 27.4% and 38.7%, respectively. There was no association between the presence of sarcopenia or myosteatosis and postoperative complications. There were also no differences in the length of stay or readmission rates. Functional recovery (time to first flatus, oral diet tolerance and mobilization) was similar regardless of the presence of muscle depletion. CONCLUSIONS In contrary to traditional surgical approach, laparoscopy can reduce the negative impact of sarcopenia and myosteatosis on treatment results. ERAS protocol does not affect negatively the surgical outcomes in sarcopenic patients, compared to patients without changes in body skeletal mass.

Enhanced recovery after colorectal surgery in elderly patients

Introduction The elderly will soon constitute 20% of the population. Their number is constantly rising, particularly in developed countries. It was found that they particularly benefit from the use of minimally invasive surgery. The Enhanced Recovery After Surgery (ERAS) protocol may further improve clinical outcomes in this group of patients. Aim To assess the implementation of the ERAS protocol in elderly patients submitted to laparoscopic colorectal surgery. Material and methods Ninety-two patients who underwent elective laparoscopic colorectal surgery were included in the study. Patients were divided into group 1 (≤ 65 years) and group 2 (> 65 years). Perioperative care was based on ERAS Society guidelines. Length of hospital stay, time of first stool passage, perioperative complications and readmissions were analyzed. Results Group 2 patients had higher ASA grades in comparison to group 1. In all cases, oral fluid intake started on the day of surgery. The groups did not differ according to oral fluid tolerance, first stool passage time or length of hospital stay. Number and character of perioperative complications were comparable between the two groups. Four patients were readmitted within 30 days after discharge. One patient required reoperation. Conclusions Implementation of the ERAS protocol is possible regardless of the age of surgical patients. Its use in the elderly allows the length of hospitalization to be shortened and is not associated with higher risk of postoperative complications or readmissions.

Minimally invasive versus open pancreatoduodenectomy—systematic review and meta-analysis

PurposeThe purpose of this systematic review was to compare minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) by using meta-analytical techniques.MethodologyMedline, Embase, and Cochrane Library were searched for eligible studies. Data from included studies were extracted for the following outcomes: operative time, overall morbidity, pancreatic fistula, delayed gastric emptying, blood loss, postoperative hemorrhage, yield of harvested lymph nodes, R1 rate, length of hospital stay, and readmissions. Random and fix effect meta-analyses were undertaken.ResultsInitial reference search yielded 747 articles. Thorough evaluation resulted in 12 papers, which were analyzed. The total number of patients was 2186 (705 in MIPD group and 1481 in OPD). Although there were no differences in overall morbidity between groups, we noticed reduced blood loss, delayed gastric emptying, and length of hospital stay in favor of MIPD. In contrary, meta-analysis of operative time revealed significant differences in favor of open procedures. Remaining parameters did not differ among groups.ConclusionOur review suggests that although MIPD takes longer, it may be associated with reduced blood loss, shortened LOS, and comparable rate of perioperative complications. Due to heterogeneity of included studies and differences in baseline characteristics between analyzed groups, the analysis of short-term oncological outcomes does not allow drawing unequivocal conclusions.

Laparoscopic Gastrectomy with Enhanced Recovery After Surgery Protocol: Single-Center Experience

Background Surgery remains the mainstay of gastric cancer treatment. It is, however, associated with a relatively high risk of perioperative complications. The use of laparoscopy and the Enhanced Recovery After Surgery (ERAS) protocol allows clinicians to limit surgically induced trauma, thus improving recovery and reducing the number of complications. The aim of the study is to present clinical outcomes of patients with gastric cancer undergoing laparoscopic gastrectomy combined with the ERAS protocol. Material/Methods Fifty-three (21 female/32 male) patients who underwent elective laparoscopic total gastrectomy due to cancer were prospectively analyzed. Demographic and surgical parameters were assessed, as well as the compliance with ERAS protocol elements, length of hospital stay, number of complications, and readmissions. Results Mean operative time was 296.4±98.9 min, and mean blood loss was 293.3±213.8 mL. In 3 (5.7%) cases, conversion was required. Median length of hospital stay was 5 days. Compliance with ERAS protocol was 79.6±14.5%. Thirty (56.6%) patients tolerated an early oral diet well within 24 h postoperatively; in 48 (90.6%) patients, mobilization in the first 24 hours was successful. In 17 (32.1%) patients, postoperative complications occurred, with 7 of them (13.2%) being serious (Clavien-Dindo 3-5). The 30-day readmission rate was 9.4%. Conclusions The combination of laparoscopy and the ERAS protocol in patients with gastric cancer is feasible and allows achieving good clinical outcomes.

The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55

UNLABELLED Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of laparoscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients. The aim of the study was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55. MATERIAL AND METHODS The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2nd Department of General Surgery of the Jagiellonian University. They were divided into two groups according to their age: ≥ 80 years of age (group1) and ≤ 55 years of age (group 2). Both groups were compared with regard to the outcome of surgery: length hospital stay, complications, hospital readmissions, degree of compliance with the ERAS protocol, and recovery parameters (tolerance of oral nutrition, mobilisation, need for opioids, restored gastrointestinal function). RESULTS Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891). CONCLUSIONS Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥ 80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse outcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.

Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study

Introduction The goal of modern medical treatment is to provide high quality medical care in a cost-effective environment. Aim To assess the cost-effectiveness of laparoscopic colorectal surgery combined with the enhanced recovery after surgery protocol (ERP) in Poland. Material and methods We designed a single-centre, case-matched study. Economic and clinical data were collected in 3 groups of patients (33 patients in each group): group 1 – patients undergoing laparoscopy with ERP; group 2 – laparoscopy without ERP; group 3 – open resection without ERP. An independent administrative officer, not involved in the treatment process, matched patients for age, sex and type of resection. Primary outcome was cost analysis. It was carried out incorporating institutional costs: hospital bed stay, anaesthesia, surgical procedure and equipment, drugs and complications. Secondary outcomes were length of stay (LOS), readmission and complication rate. Results Cost of laparoscopic procedure alone was significantly more expensive than open resection. However, implementation of the ERAS protocol reduced additional costs. Total cost per patient in group 1 was significantly lower than in groups 2 and 3 (EUR 1826 vs. EUR 2355.3 vs. EUR 2459.5, p < 0.0001). Median LOS was 3, 6 and 9 days in groups 1, 2 and 3 respectively (p < 0.001). Postoperative complications were noted in 5 (15.2%), 6 (18.2%) and 13 (39.4%) patients in groups 1, 2, 3 respectively (p = 0.0435). Conclusions In a low medical care expenditure country, minimally invasive surgery combined with ERP can be a safe and a cost-effective alternative to open surgery with traditional perioperative care.

Analysis of Laparoscopic Sleeve Gastrectomy Learning Curve and Its Influence on Procedure Safety and Perioperative Complications

PurposeLaparoscopic sleeve gastrectomy (LSG) has become an attractive bariatric procedure with promising treatment effects yet amount of data regarding institutional learning process is limited.Materials and MethodsRetrospective study included patients submitted to LSG at academic teaching hospital. Patients were divided into groups every 100 consecutive patients. LSG introduction was structured along with Enhanced Recovery after Surgery (ERAS) treatment protocol. Primary endpoint was determining the LSG learning curve’s stabilization point, using operative time, intraoperative difficulties, intraoperative adverse events (IAE), and number of stapler firings. Secondary endpoints: influence on perioperative complications and reoperations. Five hundred patients were included (330 females, median age of 40 (33–49) years).ResultsOperative time in G1–G2 differed significantly from G3–G5. Stabilization point was the 200th procedure using operative time. Intraoperative difficulties of G1 differed significantly from G2–G5, with stabilization after the 100th procedure. IAE and number of stapler firings could not be used as predictor. Based on perioperative morbidity, the learning curve was stabilized at the 100th procedure. The morbidity rates in the groups were G1, 13%; G2, 4%; G3, 5%; G4, 5%; and G5, 2%. The reoperation rate in G1 was 3%; G2, 2%; G3, 2%; G4, 1%; and G5, 0%.ConclusionThe institutional learning process stabilization point for LSG in a newly established bariatric center is between the 100th and 200th operation. Initially, the morbidity rate is high, which should concern surgeons who are willing to perform bariatric surgery.

Intravenous lipid emulsions and liver function in adult chronic intestinal failure patients: results from a randomized clinical trial

AIM Intravenous lipid emulsion (ILE) can become a risk factor for intestinal failure associated liver disease (IFALD). Many ILEs are commercially available, however, a direct comparison of their impact on liver has, to our knowledge, never been performed. The aim of the study was to analyse that clinical problem during long term parenteral nutrition (PN). METHODS A randomized, controlled clinical trial was performed at the Intestinal Failure Center in Skawina, Poland. Sixty-seven patients (37 F, 30 M, mean age 53.9 years) enrolled in home parenteral nutrition (HPN) due to stable chronic intestinal failure (CIF) were randomized to receive one the following for 12 months: long-chain triglycerides (LCT), medium/long-chain triglycerides, olive oil/LCT (OO/LCT) and a mix of LCT/MCT/OO/fish oil. Clinical evaluation and biochemical tests (total bilirubin, SGOT, SGTP, GGPT, alkaline phosphatase) were performed at enrolment and after 6 and 12 months. RESULTS the most common reason for intestinal failure (IF) was short bowel due to mesenteric ischaemia, followed by Crohns disease, surgical complications and radiation enteritis. PN stabilized liver parameters in all patients. No essential fatty acids deficiency was diagnosed. All four ILEs demonstrated comparable influence on liver in all study periods. The only exception was the decrease in total bilirubin concentration after 12 months (28.1 ± 25.3vs 11.1 ± 4.5, p = 0.0023) and GGTP (222.5 ± 205.8vs 146.6 ± 197.7, p = 0.0079) when OO/LCT was in use. CONCLUSIONS All four ILEs tested may be safe even during long-term parenteral nutrition. OO/LCT may be more effective than the others, but more studies in the field are needed.

More stapler firings increase the risk of perioperative morbidity after laparoscopic sleeve gastrectomy

Introduction Staple-line bleeding and leakage are the most common serious complications of laparoscopic sleeve gastrectomy. The relationship between multiple stapler firings and higher risk of postoperative complications is well defined in colorectal surgery but has not been addressed in bariatric procedures so far. Identification of new factors such as “the numbers of stapler firings used during laparoscopic sleeve gastrectomy (LSG)” as a predictor for complications can lead to optimization of the patient care at bariatric centers. Aim To determine the association between perioperative morbidity and the number of stapler firings during laparoscopic sleeve gastrectomy. Material and methods This observational study was based on retrospective analysis of prospectively collected data in patients operated on for morbid obesity in a teaching hospital/tertiary referral center for general surgery. The patients who underwent LSG were analyzed in terms of the number of stapler firings used as a new potential risk predictor for postoperative complications after surgery, adjusting for other patient- and treatment-related factors. The study included 333 patients (209 women, 124 men, mean age: 40 ±11). Results During the first 30 days after surgery, complications were observed in 18 (5.41%) patients. Multivariate analysis showed that prolonging operative time increased morbidity (every minute, OR = 1.01; 95% CI: 1.00–1.02) and the complication rate increased with the number of stapler firings (every firing, OR = 1.91; 95% CI: 1.09–3.33; p = 0.023). Conclusions Additional stapler firings above the usual number and a prolonged operation should alert a surgeon and the whole team about increased risk of postoperative complications.