Featured Articles in Jan 2019

The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies

 

 

Author list: Kevin M. Elias, Alexander B. Stone, Katharine McGinigle, Jo’An I. Tankou, Michael J. Scott, William J. Fawcett, Nicolas Demartines, Dileep N. Lobo, Olle Ljungqvist, Richard D. Urmanthe, ERAS® Society and ERAS® USA

 

Abstract:

Background

Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is

associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature.

 

Methods

To improve the quality of ERAS reporting, ERAS USA and the ERAS Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus.

 

Results

The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines.

 

Conclusions

The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.

 

URL: https://link.springer.com/article/10.1007/s00268-018-4753-0

 


Enhanced Recovery in Liver Transplantation: A Feasibility Study

 

 

Author list: Raffaele Brustia, Antoine Monsel, Filomena Conti, Eric Savier, Geraldine Rousseau, Fabiano Perdigao, Denis Bernard, Daniel Eyraud, Yann Loncar, Olivier Langeron, Olivier Scatton

 

Abstract:

 

Background

Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT.

 

Methods

We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery.

 

Results

Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0–10.5) days versus 18.0 (14.3–24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.

 

Conclusion

Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.

 

URL: https://rdcu.be/bd4n2

 


Cognitive Assessment of Surgeons During Surgical Procedures: Influence of Time and Intraoperative Complications

 

 

Author list: Juliana Beneduzzi, Fernando A. M. Herbella, Francisco Schlottmann, Marco G. Patti

 

Abstract:

 

Introduction

Surgeon’s performance may be influenced by several factors that may affect skills and judgement, which ultimately represents surgeon´s cognition. Cognition refers to all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem solving. This report aims to evaluate the effect of operative time and operative complications on surgeon´s cognition.

 

Methods

Forty-six surgeons (mean age 31 years, 78% males) assigned to an operation expected to last for at least 2 h, volunteered for the study. All participants underwent 3 cognitive tests at the beginning of the operation and hourly, until the end of the procedure: (a) concentration (serial sevens, counting down from 100 by sevens); (b) visual (fast counting, counting the number of circles with the same color among a series of circles); and (c) motor (trail making, connecting a set of numbered dots). Intraoperative complications were recorded.

 

Results

The visual test had a stable behavior along time. Concentration and motor tests tend to be performed faster. Intraoperative complications occurred in 5 (11%) cases (3 hemorrhage and 2 organ injuries). Performance time was stable for concentration and motor tests but visual test tends to be performed faster in cases with an intraoperative complication.

 

Conclusion

Our results showed that (1) time does not jeopardize surgeons’ cognition, but rather surgeons learned to perform the tests faster, and (2) complications do not decrease surgeons’ cognition.

 

URL: https://rdcu.be/bd4or

 


Incidental Gallbladder Cancer: How Residual Disease Affects Outcome in Two Referral HPB Centers from South America

 

 

Author list: Luis Gil, Xabier de Aretxabala, Javier Lendoire, Fernando Duek, Juan Hepp, Oscar Imventarza

 

Abstract:

Background

Residual disease (RD) has been described as one of the most relevant prognostic factors after radical surgical resection for incidental gallbladder cancer (IGC). The purpose of the present study was to analyze patterns of RD and determinant prognostic factors in patients undergoing re-resection for IGC.

 

Methods

Patients undergoing re-exploration due to IGC between 1990 and 2014 were identified in two referral centers from different South-American countries. Patients submitted to a radical definitive operation were included in the study. Demographics and tumor-treated related variables were analyzed in correlation with RD and survival. The site of RD, local (gallbladder bed) or regional (lymph nodes and bile duct) was correlated with disease-specific survival (DSS).

 

Results

Of 265 patients with IGC submitted to surgery, 168 underwent a radical re-resection and RD was found in 58 (34.5%). Demographic, clinical and surgical variables were compared between both centers showing differences in type of resection, laparoscopic approach, T stages and disease stage. Location of RD was regional in 34 (20.2%) and local in 24 (14.3%), and no residual disease was found in 110 (65.5%) patients. T stage (T1b = 20%, T2 = 23.8%, T3 = 71.7%, p < 0.001) and disease stage (p < 0.001) were independent predictors of RD. Finding RD at any location reduced the DSS in comparison with non-RD patients (19.6 months vs. 62.7 months p < 0.001). No differences in DSS according to the location of RD were found, and all anatomic sites were equally poor (p = 0.27). RD at any site predicted DSS (p < 0.001), independently of all other IGC variables.

 

Conclusions

IGC presented similar clinical parameters in two different countries of South America. RD was demonstrated as the most critical prognostic variable in patients with IGC treated by a radical resection. The presence of RD was associated with poor outcome, independently of any anatomic location. Future studies incorporating neoadjuvant chemotherapy in the treatment of patients with prognostic factors for RD are required to improve survival in this entity.

 

URL: https://rdcu.be/bd4oM

 


Outcomes Following Non-operative Management of Thoracic and Thoracoabdominal Aneurysms

 

 

Author list: Gabriele Piffaretti, Alessandro Bacuzzi, Andrea Gattuso, Gaddiel Mozzetta, Maria Cristina Cervarolo, Walter Dorigo, Patrizio Castelli, Matteo Tozzi

 

Abstract:

 

Background

Surgical decision making remains difficult in several patients with aneurysmal disease of the descending thoracic (DT) or thoracoabdominal (TA) aorta. Despite previous studies that have investigated aneurysms treated non-operatively using a prospective growth analysis, completeness and accuracy of follow-up were inconsistent. We aim to describe the survival and freedom from adverse aortic events in patients with DT and TA who did not undergo operative repair.

 

Methods

This is a single-center retrospective analysis of all patients with either a descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion who were treated non-operatively from April 2002 to December 2016. We studied patients who did not undergo operative repair of descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion. Primary end points were overall survival and freedom from aortic-related mortality (ARM).

 

Results

Of the 315 patients diagnosed with DT or TA disease, 56 (18%) did not undergo surgical repair. Mean aneurysm diameter was 65 mm ± 15 (range 50–120; IQR 5.4–7.15). Extent of the aortic aneurysms was DT in 36 (11%) patients and TA in 20 (6%). Median duration of follow-up was 12 months (range 1–108; IQR 3–36). Over the course of the study, 41 (73%) patients died for an overall survival rate of 53% ± 7 at 1 year (95% CI 40–65) and 23% ± 7 at 3 year (95% CI 17–42.5). Aortic-related mortality was 27% (n = 15), significantly higher in patients with aneurysms ≥ 60 mm [n = 13, (39%) vs. n = 2, (9%); P = 0.025; OR = 5.04]. Overall, estimated freedom from ARM was 81% ± 5.5 at 1 year (95% CI 68–89) and 66.5% ± 9 at 3 year (95% CI 48–81). Only TA extent was independently associated with freedom from ARM during the follow-up (P = 0.005; HR: 5.74; 95% CI 1.711–19.729).

 

Conclusions

Thoracoabdominal extent of the aneurysmal aortic disease is the most important predictor of ARM in unrepaired DT or TA aortic diseases. Mortality from aortic-related events was significantly more premature than mortality from non-aortic-related mortality.

 

URL: https://rdcu.be/bd4o5

 


Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis

 

 

Author list: Mélissa Roy, Joseph P. Corkum, David R. Urbach, Christine B. Novak, Herbert P. von Schroeder, Steven J. McCabe, Karen Okrainec

 

Abstract:

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients’ health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7–39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5–39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

 

URL: https://rdcu.be/bd4pB

 


 

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