Michał Pędziwiatr

Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol – Compliance improves outcomes: A prospective cohort study

Enhanced Recovery After Surgery protocol in colorectal surgery allows shortening length of hospital stay and reducing complication rate. Despite the clear guidelines and conclusive evidence their full implementation and putting them into daily practice meets certain difficulties, especially in the early stage. The aim of the study was to analyse the course of implementation of the ERAS protocol into daily practice on the basis of adherence to the protocol. Group included 92 patients (43F/49M) with colorectal cancer submitted to laparoscopic resection during the years 2013-2014. Perioperative care in all of them based on ERAS protocol consisting of 16 items. Its principles and discharge criteria were based on the guidelines of the ERAS Society guidelines. The entire analysed group of patients was divided into 3 subgroups (30 patients) depending on the time from ERAS protocol implementation. We analysed the compliance with the protocol and its influence on length of hospital stay, postoperative complications and readmission rate in different subgroups. The average compliance with the protocol differed significantly between groups and was 65% in group 1, 83.9% in group 2 and 89.6% in group 3. The compliance with subsequent protocol elements was different. The length of stay and complication rate was statistically different in analysed subgroups. The whole group demonstrated an inverse correlation between compliance and length of stay. This analysis leads to the conclusion that the introduction of the ERAS protocol is a gradual process, and its compliance at the level of 80% or more requires at least 30 patients and the period of about 6 months. The initial derogation from the assumed proceedings is inevitable and should not discourage further action. Particular emphasis in the initial stage should be put on continuous training of personnel of all specialties and continuous evaluation of the results.

One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery.

Background Obese patients are a very large high-risk group for complications after surgical procedures. In this group, optimized perioperative care and a faster recovery to full activity can contribute to a decreased rate of postoperative complications. The introduction of ERAS®-based protocol is now even more important in bariatric surgery centers. The results of our study support the idea of implementation of ERAS®-based protocol in this special group of patients. Material/Methods This analysis included 170 patients (62 male/108 female, mean BMI 46.7 kg/m2) who had undergone laparoscopic bariatric surgery, and whose perioperative care was conducted according to a protocol inspired by ERAS® principles. Examined factors included oral nutrition tolerance, time until mobilization after surgery, requirements for opioids, duration of hospitalization, and readmission rate. Results During the first 24 postoperative hours, oral administration of liquid nutrition was tolerated by 162 (95.3%) patients and 163 (95.8%) were fully mobile. In 44 (25.8%) patients it was necessary to administer opioids to relieve pain. Intravenous liquid supply was discontinued within 24 hours in 145 (85.3%) patients. The complication rate was 10.5% (mainly rhabdomyolysis and impaired passage of gastric contents). The average time of hospitalization was 2.9 days and the readmission rate was 1.7%. Conclusions The introduction of an ERAS® principles-inspired protocol in our center proved technically possible and safe for our patients, and allowed for reduced hospitalization times without increased rate of complications or readmissions.

Short hospital stays after laparoscopic gastric surgery under an Enhanced Recovery After Surgery (ERAS) pathway: experience at a single center.

SummaryIntroductionRecently, first reports on benefits from Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing gastric surgery have appeared. It seems that maximal reduction of unfavorable surgery-induced trauma in patients with gastric malignancy via ERAS protocol combined with minimally invasive techniques can improve outcomes.ObjectiveThe aim of this study was to determine the influence of laparoscopic surgery and ERAS protocol in oncological gastric surgery on early outcomes.Materials and methodsProspective analysis involved 28 patients (18 female and 10 male) with gastric malignancy who underwent laparoscopic gastric resection between 2009 and 2013. Gastric tumors (gastrointestinal stromal tumors or adenocarcinoma) were the indication for the surgery. A total of 17 patients underwent laparoscopic local excision, and 11 patients with adenocarcinoma or multiple neuroendocrine tumors underwent laparoscopic D2 total gastrectomy. Perioperative care was based on ERAS principles. Length of hospital stay, postoperative course, perioperative complications, and readmission rates were analyzed.ResultsThere was one conversion in the gastrectomy group. All patients were mobilized on the day of surgery. Oral fluids were introduced on day 0 and were well tolerated. Full hospital diet was started on day 2 in all patients, but was well tolerated in only 18 of them. One postoperative complication requiring reoperation was noted. The length of stay after gastrectomy and gastric wedge resection was 4.6 (2–6) and 3.3 (2–6) days, respectively. No readmissions were noted in the entire group.ConclusionsThe implementation of ERAS protocol to clinical practice in combination with laparoscopy in patients with gastric tumors can result in improved postoperative care quality, shortening of hospital stay, and quicker return to normal activity.

Cystic adrenal lesions - analysis of indications and results of treatment.

UNLABELLED Cysts are a rare pathology of adrenal glands. As the development of new diagnostic techniques takes place, the occurrence of adrenal cystic lesions has been rapidly increasing. The majority of them are solid adrenal lesions, but localized fluid collections are also more frequently diagnosed. In case of solid adrenal lesions, there are straight indications for surgery, but on the other hand there are no clear guidelines and recommendations in case of adrenal cysts. The aim of the study was to analyze surgical methods and evaluate treatment effects in patients who were qualified for laparoscopic adrenalectomy due to adrenal cystic lesions. METARIAL AND METHODS: Identical criteria were used to qualify patients with solid and cystic lesions of the adrenal gland for surgery. Out of the whole number of 345 patients who underwent laparoscopic surgery for adrenal tumors, 28 had adrenal cysts. 16 of them (57%) were women and 12 (43%) men. The average age of the studied group was 46.4 years (25-62 years). The average cyst diameter in CT was 5.32 cm (1.1-10 cm). Most of the lesions were hormonally inactive (22 patients), but in 6 cases increased level of adrenal hormones was observed. RESULTS Pathological analysis revealed 4 (14%) pheochromocytomas and 2 (7%) dermoid cysts. In case of 22 (79%) patients, the postoperative material was profiled by pathologists as insignificant according to potential neoplasmatic transformation risk: 5 (17.5%) - endothelial vascular cysts, 3 (11%) endothelial lymphatic cysts, 7 (25.5%) pseudocysts, 3 (11%) simple cysts, 2 (7%) bronchogenic cysts, 1 (3.5%) - cortical adenoma and 1 (3.5%) cyst was of myelolipoma type. CONCLUSIONS Based on the performed research and previous experience in treating patients with adrenal lesions we can conclude that application of the same evaluating algorithm for both cystic and solid lesions is valid.

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.

SILS (Single Incision Laparoscopic Surgery) – new surgical approach to peritoneal cavity

PURPOSE The objective of the modern surgery is not only to perform surgical procedures aiming to improve the health condition of the patient, but whenever possible to use minimally invasive approach and to ensure the satisfying cosmetic result. During the last years we can observe an intense development of surgical technique minimizing the access to peritoneal cavity to just one small incision, most frequently localized in the umbilicus. MATERIAL/METHODS Between October 2009 and May 2010 an overall number of 34 laparoscopic procedures through a single abdominal wall incision were performed at the 2nd Department of Surgery, Jagiellonian University, Medical College in Krakow. There were 28 women and 6 men in the study group ranging in age from 19 - 76 years. Among indications for surgery there were: symptomatic gallbladder stones (21 patients), adrenal gland tumours (8 patients), ITP - Immune Thromocytopenic Purpura (2 patients), appendicitis (2 patients) and splenic cyst (one patient). RESULTS There were 31 out of 34 procedures completed with pure Single Incision Laparoscopic Surgery (SILS) technique as intended preoperatively without any intraoperative complications. In 3 patients additional trocars were needed for safe continuation of the procedure. There were no intraoperative complications. The mean operating time was 82 minutes ranging from 25 minutes (appendectomy) to 180 minutes (right adrenalectomy). Mean intraoperative blood loss was 0 - 30 ccm. CONCLUSIONS SILS surgical procedures constitute the next step in the development of minimally invasive surgery. In the hands of experienced surgeon this particular technique may constitute a safe alternative for classical laparoscopy.

Cost-effective, personalized, 3D-printed liver model for preoperative planning before laparoscopic liver hemihepatectomy for colorectal cancer metastases

PurposeThree-dimensional (3D) printing for preoperative planning has been intensively developed in the recent years. However, the implementation of these solutions in hospitals is still difficult due to high costs, extremely expensive industrial-grade printers, and software that is difficult to obtain and learn along with a lack of a defined process. This paper presents a cost-effective technique of preparing 3D-printed liver models that preserves the shape and all of the structures, including the vessels and the tumor, which in the present case is colorectal liver metastasis.MethodsThe patient’s computed tomography scans were used for the separation and visualization of virtual 3D anatomical structures. Those elements were transformed into stereolithographic files and subsequently printed on a desktop 3D printer. The multipart structure was assembled and filled with silicone. The patient underwent subsequent laparoscopic right hemihepatectomy. The entire process is described step-by-step, and only free-to-use and mostly open-source software was used.ResultsAs a result, a transparent, full-sized liver model with visible vessels and colorectal metastasis was created for under

Single center outcomes of laparoscopic transperitoneal lateral adrenalectomy – Lessons learned after 500 cases: A retrospective cohort study

150, which—taking into account 3D printer prices—is much cheaper than models presented in previous research papers.ConclusionsThe increased accessibility of 3D models for physicians before complex laparoscopic surgical procedures such as hepatic resections could lead to beneficial breakthroughs in these sophisticated surgeries, as many reports show that these models reduce operative time and improve short term outcomes.

Do we really need routine drainage after laparoscopic adrenalectomy and splenectomy

INTRODUCTION Although laparoscopic adrenalectomy is considered relatively safe, the results of treatment vary depending on the profile of the hospital. We would like to present our experience with laparoscopic surgery of the adrenals. METHODS We conducted a retrospective cohort study of consecutive patients operated for adrenal tumours in the years 2003-2014. The study group included 175 (35%) men and 325 (65%) women. The entire group was divided into 4 cohorts of 125 consecutively operated patients. Primary outcomes were operative measures (operative time, its correlation with tumour size, blood loss, conversion rate, use of peritoneal drainage). Secondary outcomes were the intra- and postoperative complications (using the Clavien-Dindo classification), histological type of the tumours and length of hospital stay. RESULTS There were no differences between groups in terms of the size and location of the tumour. The mean operative time in each group was 85.7; 83.7; 89.6; 104.6 min (p < 0.001). The operative time correlated to the size of the tumour. There were no differences in the conversion rates as well as in the blood loss. However, it was observed that the complication rate was declining in subsequent subgroups (14.4%, 11.2%, 8% and 5.6%, respectively, p = 0.013). Length of hospital stay was 4.9 days, 3.9 days, 2.9 days, 2.4 days, respectively (p < 0.001). CONCLUSION The results of laparoscopic adrenalectomy depend not only on the experience of the single surgeon, but on the whole team involved in perioperative care. In high volume centers with extensive experience in surgery of adrenals, this technique may provide an alternative to open surgery, also in selected cases of malignant tumours.

Are bariatric operations performed by residents safe and efficient

Introduction Not only did the introduction of laparoscopy not dispel the controversy over routine drainage after uncomplicated surgery, but paradoxically it contributed to enlivening the debate on the issue. Aim To determine the usefulness of operative site drainage after “clean”, uncomplicated laparoscopic surgery such as splenectomy or adrenalectomy. Material and methods One hundred and seventy-six participants (female : male 114 : 62) operated on in our centre between Jan 2008 and Nov 2010 were included in the prospective study. Adrenalectomy was performed in 122 patients and splenectomy in 54. In some patients no drains were left after the procedure, while the others had drainage employed. The incidence and character of post-operational complications, the necessity of repeat surgery and the length of the hospital stay were analysed. Results In 112 patients (63.6%) the drain was inserted in the operational field, while in the remaining 64 (36.4%) it was not. Out of the whole series of 112 patients with drainage used, complications were observed in 6 cases (5.36%) while in the group of patients without drainage they appeared in 2 (3.12%) of those operated on (p < 0.05). Infectious complications were observed more often in the series with drainage (3.57% vs. 0%, p < 0.05). The hospital stay in patients with drainage was statistically significantly longer than in patients without. Conclusions Based on the study, no justification for routine drainage after scheduled, uncomplicated laparoscopic adrenalectomy and splenectomy was found. The decision whether to leave a drain should be made for every patient individually.