| 1. |
- Gustafsson, Ulf O., et al.
(author)
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Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery : A Retrospective Cohort Study
- 2016
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In: World Journal of Surgery. - New York, USA : Springer. - 0364-2313 .- 1432-2323. ; 40:7, s. 1741-1747
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Journal article (peer-reviewed)abstract
- Background: Surgical stress can influence oncological outcome and survival. The enhanced recovery after surgery (ERAS) protocol is designed to reduce perioperative stress and has been shown to reduce postoperative morbidity. We studied if adherence to ERAS is associated with increased long-term survival.Methods: Between the years 2002 and 2007, 911 consecutive patients, operated with major colorectal cancer surgery at Ersta Hospital, Stockholm, Sweden were analyzed. The histopathological reports of the resected specimen, date, and cause of death of the patients as well as postoperative CRP levels were obtained. The relation between the rate of adherence to the ERAS protocol at the time of surgery, and the short-term outcomes in relation to 5-year overall and colorectal cancer-specific survival was determined in this retrospective cohort study.Results: In patients with ≥70 % adherence to ERAS interventions (N = 273,), the risk of 5-year cancer-specific death was lowered by 42 %, HR 0.58 (0.39-0.88, cox regression) compared to all other patients (<70 % adherence). Significant independent perioperative predictors of increased 5-year survival were avoiding overload of intravenous fluids, HR 0.53 (0.32-0.86); oral intake on the day of operation, HR 0.55 (0.34-0.78); and low CRP levels on postoperative day 1.Conclusion: High adherence to the ERAS protocol may be associated with improved 5-year cancer-specific survival after colorectal cancer surgery.
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| 2. |
- Pędziwiatr, Michał, et al.
(author)
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Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?
- 2016
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In: Medical Oncology. - Heidelberg, Germany : Springer. - 1357-0560 .- 1559-131X. ; 33:3
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Journal article (peer-reviewed)abstract
- There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay-LOS (75 patients in group 1-≤4 days, 68 patients in group 2->4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.
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| 3. |
- Thanh, Nguyen X., et al.
(author)
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An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta
- 2016
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In: Canadian journal of surgery. - Ottowa, Canada : Canadian Medical Association. - 0008-428X .- 1488-2310. ; 59:6, s. 415-421
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Journal article (peer-reviewed)abstract
- Background: In February 2013, Alberta Health Services established an Enhanced Recovery After Surgery (ERAS) implementation program for adopting the ERAS Society colorectal guidelines into 6 sites (initial phase) that perform more than 75% of all colorectal surgeries in the province. We conducted an economic evaluation of this initiative to not only determine its cost-effectiveness, but also to inform strategy for the spread and scale of ERAS to other surgical protocols and sites.Methods: We assessed the impact of ERAS on patients' health services utilization (HSU; length of stay [LOS], readmissions, emergency department visits, general practitioner and specialist visits) within 30 days of discharge by comparing pre- and post-ERAS groups using multilevel negative binomial regressions. We estimated the net health care costs/savings and the return on investment (ROI) associated with those impacts for post-ERAS patients using a decision analytic modelling technique.Results: We included 331 pre- and 1295 post-ERAS patients in our analyses. ERAS was associated with a reduction in all HSU outcomes except visits to specialists. However, only the reduction in primary LOS was significant. The net health system savings were estimated at $2 290 000 (range $1 191 000-$3 391 000), or $1768 (range $920-$2619) per patient. The probability for the program to be cost-saving was 73%-83%. In terms of ROI, every $1 invested in ERAS would bring $3.8 (range $2.4-$5.1) in return.Conclusion: The initial phase of ERAS implementation for colorectal surgery in Alberta is cost-saving. The total savings has the potential to be more substantial when ERAS is spread for other surgical protocols and across additional sites.
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| 4. |
- Ahl, Rebecka, 1987-, et al.
(author)
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The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer
- 2019
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In: World Journal of Surgery. - : Springer. - 0364-2313 .- 1432-2323. ; 43:10, s. 2527-2535
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Journal article (peer-reviewed)abstract
- BACKGROUND: Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.STUDY DESIGN: This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.RESULTS: A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055).CONCLUSION: The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.
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| 5. |
- Batchelor, Timothy J. P., et al.
(author)
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Guidelines for enhanced recovery after lung surgery : recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)
- 2019
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In: European Journal of Cardio-Thoracic Surgery. - : Springer. - 1010-7940 .- 1873-734X. ; 55:1, s. 91-115
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Research review (peer-reviewed)abstract
- Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.
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| 6. |
- Dort, Joseph C., et al.
(author)
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Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction : A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society
- 2017
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In: JAMA Otolaryngology - Head and Neck Surgery. - Chicago, USA : American Medical Association. - 2168-6181 .- 2168-619X. ; 143:3, s. 292-303
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Research review (peer-reviewed)abstract
- Importance: Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking.Objective: To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.Evidence Review: Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral cavity resection," "glossectomy," and "head and neck." The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel.Findings: The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.Conclusions and Relevance: The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.
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| 7. |
- Ljungqvist, Olle, 1954-
(author)
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ERAS-enhanced recovery after surgery : moving evidence-based perioperative care to practice
- 2014
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In: JPEN - Journal of Parenteral and Enteral Nutrition. - : Sage Publications. - 0148-6071 .- 1941-2444. ; 38:5, s. 559-566
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Journal article (peer-reviewed)abstract
- ERAS is the acronym for enhanced recovery after surgery, a term often used to describe perioperative care programs that have been shown to improve outcomes after major surgery. This article gives a brief history of the development from fast-track surgery to ERAS. Today, the full meaning of ERAS goes beyond just a protocol for perioperative care with the initiation of a novel multiprofessional, multidisciplinary medical society: the Enhanced Recovery After Surgery Society for Perioperative Care (www. erassociety. org). The ERAS Society is involved in the development of evidence-based guidelines. These guidelines form the basis for an implementation program of the ERAS principles to practice. While ERAS was initially developed for colonic resections, these principles are being used in a range of operations, and there is also a continuous update of care protocols as the fields develop. A key mechanism behind the effectiveness of ERAS is the dampening of the stress responses to the surgical insult combined with the use of treatments that support return of functions that delay recovery in traditional care. The article also gives some insights to why the protocols work and reports the effects of ERAS protocols.
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| 8. |
- Ware, James, et al.
(author)
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Glucose, insulin and osmolar changes in rats sustaining different haemorrhage volumes.
- 1982
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In: Acta Physiologica Scandinavica. - : Almqvist & Wiksell. - 0001-6772 .- 1365-201X. ; 116:1, s. 31-36
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Journal article (peer-reviewed)abstract
- Plasma glucose, osmolality and insulin have been investigated during hemorrhage in nonstarved rats. The rate of blood loss leading to hemorrhages of 44% and 55% of the estimated original blood volume determined the patterns of response. Substantial hyperglycemic hyperosmolality and insulin values appropriate for the raised levels of glucose were observed in the animals bleeding more rapidly. The slower rate of hemorrhage was associated with only moderate hyperglycemia and hyperosmolality, while the insulin values rose to very high levels, 45 times basal. It is postulated that altered glucose‐insulin metabolism in haemorrhage may have important consequences for fluid homeostasis, and the rate of bleeding is the fundamental factor steering this effect. © 1982 Scandinavian Physiological Society
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| 9. |
- Ahl, Rebecka, 1987-, et al.
(author)
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Does beta-blockade reduce the risk of depression in patients with isolated severe extracranial injuries?
- 2017
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In: World Journal of Surgery. - New York : Springer. - 0364-2313 .- 1432-2323. ; 41:7, s. 1801-1806
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Journal article (peer-reviewed)abstract
- BACKGROUND: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury.METHODS: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma.RESULTS: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02).CONCLUSIONS: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.
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