ERAS: Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review
Author list - Gaëtan-Romain Joliat, Martin Hübner, Didier Roulin & Nicolas Demartines
Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings.
A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.
Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370–650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600–2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.
The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
URL – https://rdcu.be/b0Sqr
Stepwise Approach for Parathyroid Localisation in Primary Hyperparathyroidism
Author list – Vijay Korwar, Fernando Yuen Chang, Ella Teasdale, Ivo Suchett-Kaye, Anusha Edwards & Justin Morgan
Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral neck exploration to selective parathyroidectomy. Several imaging modalities, each with varying sensitivities, are available to detect abnormal parathyroid glands. Ultrasound is almost universally accepted as the first line radiological investigation however its sensitivity is particularly heterogeneous and operator-dependent.
Material and methods
We studied 250 consecutive patients with PHPT who underwent parathyroidectomy in our hospital over a period of 33 months. Pre-operative neck ultrasound, 99mTc-sestamibi and single-photon emission computed tomography (SPECT CT) were performed in 249, 237 and 198 patients respectively. Unilateral and bilateral neck exploration was performed in 190 and 60 patients, respectively. Sensitivity, positive predictive value (PPV) and accuracy were calculated comparing the results with surgical and pathology findings.
Mean pre and postoperative PTH and adjusted calcium were, 11 ± 10.6 pmol/L, 1.9 ± 3.6, 2.81 ± 0.2 and 2.45 ± 0.2 mmol/L. There were 71 (29.95%) discordant results between US, compared to sestamibi and SPECT CT. An average of 1.9 parathyroid glands were removed with a mean weight of 0.92 g. Overall success rate based on postoperative PTH levels was 94.8%. Overall sensitivity, PPV and accuracy for US were 80.80%, 92.35%, and 75.73% respectively; for sestamibi were 71.82%, 94.61%, 69.00% and for SPECT CT were; 70.21%, 97.78%, 69.11% respectively.
Ultrasound performed by an experienced specialist sonographer is highly sensitive in localising abnormal parathyroid glands. It can be used as a main and sole investigation in the majority of patients. Sestamibi, SPECT CT and other investigations should be performed in a step-wise manner and reserved for patients with negative US, failed primary procedure and recurrences.
URL - https://rdcu.be/b0SrW
Long-Term Quality of Life After Total Gastrectomy Versus Ivor Lewis Esophagectomy
Author list – E. Jezerskyte, L. M. Saadeh, E. R. C. Hagens, M. A. G. Sprangers, L. Noteboom, H. W. M. van Laarhoven, W. J. Eshuis, M. I. van Berge Henegouwen & S. S. Gisbertz
There is scarce evidence on whether a total gastrectomy or an Ivor Lewis esophagectomy is preferred for gastroesophageal junction (GEJ) cancers regarding effects on morbidity, pathology, survival and health-related quality of life (HR-QoL). The aim of this study was to investigate the difference in long-term HR-QoL in patients undergoing total gastrectomy versus Ivor Lewis esophagectomy in a tertiary referral center.
Patients with a follow-up of >1 year after a total gastrectomy or an Ivor Lewis esophagectomy for GEJ/cardia carcinoma completed the EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires. ‘Problems with eating,’ ‘reflux,’ and ‘nausea and vomiting’ were the primary HR-QoL endpoints. The secondary endpoints were the remaining HR-QoL domains, postoperative complications and pathology results.
Thirty patients after gastrectomy and 71 after esophagectomy were included. Mean age was 63 years. Median follow-up was 2 years (range 12–84 months). Patients after gastrectomy reported less ‘choking when swallowing’ and ‘coughing’ (β = − 5.952, 95% CI − 9.437 to − 2.466; β = − 13.084, 95% CI − 18.525 to − 7.643). More lymph nodes were resected in esophagectomy group (p = 0.008). No difference was found in number of positive lymph nodes, R0 resection or postoperative complications.
After a follow-up of >1 year ‘choking when swallowing’ and ‘coughing’ were less common after a total gastrectomy. No differences were found in postoperative complications or radicality of surgery. Based on this study, no general preference can be given to either of the procedures for GEJ cancer. These results support shared decision making when a choice between the two treatment options is possible.
URL – https://rdcu.be/b0SsW
The Pathophysiology, Presentation and Management of Ischaemic Colitis
Author list - George Demetriou, Ahmed Nassar & Sriram Subramonia
There are currently no guidelines on the long-term management of patients after an episode of acute ischaemic colitis. Our aim was to review the literature on the pattern of presentation and the pathophysiology of this condition and to understand the current status of the acute and long-term management of ischaemic colitis. Furthermore, we aim to provide recommendations for the clinicians in regard to the acute and long-term management of ischaemic colitis. A review of the English literature over the last 15 years was performed using Embase and Medline. Search terms were ischaemic OR ischemic, colitis OR colon. Two reviewers screened the papers against pre-determined eligibility criteria. A senior consultant surgeon performed a final overview. Three hundred sixty-eight papers were identified on the initial search; 318 were irrelevant and 17 were conference abstracts; both were excluded. Thirty-three full articles were assessed for suitability; nine were further excluded. Twenty-four articles were included in the final analysis and cross-referenced against those listed in the systematic reviews. There is a large clinical heterogeneity in inclusion criteria (histological, radiological, endoscopic, surgical specimen). Twelve out of 24 articles included patients only based on histological diagnosis. The definition of right and left (or nonright) ischaemic colitis was variable based on whether hepatic or splenic flexure was used as the cut-off point. Five retrospective case series highlighted that patients with isolated right-sided ischaemic colitis had a worse prognosis than those with left-sided colitis (higher mortality, need for surgery, length of hospital stay). The overall recurrence was 9%. There is a need for a higher-level evidence to guide clinicians on the long-term management of patients following an episode of acute colonic ischaemia. Further evidence is required to determine whether right colonic ischaemia should be managed differently from left.
URL – https://rdcu.be/b0Ss6
Ability of Laparoscopic Gastric Mobilization to Prevent Pulmonary Complications After Open Thoracotomy or Thoracoscopic Esophagectomy for Esophageal Cancer
Author list –Eisuke Booka, Yasuhiro Tsubosa, Ryoma Haneda & Kenjiro Ishii
Esophagectomy has a high risk of postoperative morbidity, and pulmonary complications are the most common causes of serious morbidity. Thoracoscopic esophagectomy has been reported to reduce postoperative pulmonary complications; however, it remains unclear whether laparoscopic gastric mobilization can reduce the occurrence of postoperative pulmonary complications after open thoracotomy or thoracoscopic esophagectomy. The present meta-analysis assessed the ability of laparoscopic gastric mobilization to prevent postoperative complications after open thoracotomy or thoracoscopic esophagectomy.
Studies reported between January 2000 and April 2019 in the PubMed and the Cochrane Library databases that analyzed the impact of laparoscopy on postoperative complications were systematically reviewed. In the meta-analysis, data were pooled and the primary outcome was postoperative pulmonary complications. The secondary outcomes were other postoperative complications, operative details, length of hospital stay and postoperative mortality.
A total of 13 studies (1915 patients; 1 randomized trial, 1 prospective study and 11 observational studies) were included. Laparoscopic gastric mobilization after open thoracotomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.47, 95% confidence interval (CI): 0.27–0.82, p = 0.008) and postoperative mortality (OR = 0.49, 95%CI: 0.25–0.94, p = 0.03). Similarly, laparoscopic gastric mobilization after thoracoscopic esophagectomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.56, 95%CI: 0.37–0.84, p = 0.005) and anastomotic leakage (OR = 0.59, 95%CI: 0.39–0.91, p = 0.02).
Laparoscopic gastric mobilization could be recommended for reducing postoperative pulmonary complications after esophagectomy irrespective of the thoracic approach.
URL - https://rdcu.be/b0Stj