Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study.

INTRODUCTION: It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP. MATERIALS AND METHODS: Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined. RESULTS: Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001). CONCLUSIONS: The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

Diffusion de la réhabilitation améliorée après chirurgie en France. Étude nationale à grande échelle, à partir des données du PMSI.

INTRODUCTION: The aim of this study was to analyze the rate of enhanced recovery programs (ERP) implementation in a range of surgical specialties in both the public and private sectors. METHODS: This was a retrospective longitudinal study based on hospital stays between March to December 2019. We studied thirteen of the activity segments most frequently included in ERP protocol. The procedures selected included digestive, gynecological, orthopedic, thoracic, and urological procedures. The assessment criteria was the rate of ERP. The results were analyzed first overall and then matching ERP stays to non-ERP stays according to type of institution, patient age and sex, month of discharge, and Charlson comorbidity score. RESULTS: We took 420,031 stays into account, of which 78,119 were coded as ERP. There were 62,403 non-ERP stays. Depending on the type of surgery, the implementation rate ranged from 5 percent to 30 percent. The overall rate of ERP implementation was higher in the private sector (21.2 percent) than in the public sector (14.4 percent). The results are reversed for some surgeries, notably for some cancers. Patients had a higher Charlson score in the public sector. CONCLUSIONS: This large-scale national study provides a picture of the degree of diffusion of ERPs in France. Although there are differences between sectors, this diffusion is still insufficient overall. Given the demonstrated benefits of ERPs, more educational efforts are needed to improve their implementation in France.

Impact of preoperative treatment with antidepressants and/or anxiolytics on outcomes after colorectal surgery with an enhanced recovery programme: a monocentric retrospective study.

BACKGROUND: Preoperative use of antidepressants and anxiolytics was reported to increase length of hospital stay (LOS) and worsen surgical outcomes. However, the surgical procedures studied were seldom performed with an enhanced recovery programme (ERP). This study investigated whether these medications impaired postoperative recovery after colorectal surgery with an ERP. METHODS: The data of all patients scheduled for colorectal surgery between November 2015 and December 2019 prospectively included in our database were analysed. All the patients were managed with the same ERP. Demographic data, risk factors, incidence of postoperative complications, LOS, and adherence to the ERP were compared between patients with and without preoperative antidepressant and/or anxiolytic treatment. RESULTS: Of the 502 patients, 157 (31.3%) were treated with antidepressants and/or anxiolytics. They were older (65.7 vs. 59.5 years, p < 0.001), sicker (higher ASA physical status score, p = 0.001), and underwent surgery more frequently for cancer (73.9 vs. 56.8%, p < 0.001). Overall adherence to ERP (p = 0.99) and adherence to the postoperative items of ERP (p = 0.29), incidence of postoperative complications (35.7 vs. 33.2%, p = 0.61), and LOS (4 [2-7] vs. 4 [2-7], p = 0.99) were similar in the two groups. CONCLUSIONS: Our findings suggest that preoperative treatment with antidepressants and/or anxiolytics does not worsen outcome after elective colorectal surgery with an ERP, does not impact adherence to ERP, and does not prolong LOS. ERP seems efficacious in patients treated with these medications, who should therefore not be excluded from this programme.

Acute urinary retention and urinary tract infection after short-course urinary drainage in colon or high rectum anastomoses: Post hoc analysis of a multicentre prospective database from the GRACE group.

AIM: The aim was to define the risk factors for acute urinary retention (AUR) and urinary tract infections (UTIs) in colon or high rectum anastomosis patients based on the absence of a urinary catheter (UC) or the early removal of the UC (<24 h). METHOD: This is a multicentre, international retrospective analysis of a prospective database including all patients undergoing colon or high rectum anastomoses. Patients were part of the enhanced recovery programme audit, developed by the Francophone Group for Enhanced Recovery after Surgery, and were included if no UC was inserted or if a UC was inserted for <24 h. RESULTS: In all, 9389 patients had colon or high rectum anastomoses using laparoscopy, open surgery or robotic surgery. Among these patients, 4048 were excluded because the UC was left in place >24 h (43.1%) and 97 were excluded because the management of UC was unknown (1%). Among the 5244 colon or high rectum anastomoses patients included, AUR occurred in 5.2% and UTI occurred in 0.7%. UCs were in place for <24 h in 2765 patients (52.7%) and 2479 did not have UCs in place (47.3%). Multivariate analysis showed that management of the UC was not significantly associated with the occurrence of AUR and that risk factors for AUR were male gender, ≥65 years old, having an American Society of Anesthesiologists score ≥3 and receiving epidural analgesia. Conversely, being of male gender was a protective factor of UTI, while being ≥65 years old, having open surgery and receiving epidural analgesia were risk factors for UTIs. The management of the UC was not significantly associated with the occurrence of UTIs but the occurrence of AUR was a more significant risk factor for UTIs. CONCLUSION: UCs in place for <24 h did not reduce the occurrence of AUR or UTI compared to the absence of UCs.

The impact of orthostatic intolerance on early ambulation following abdominal surgery in an enhanced recovery programme.

BACKGROUND: The prevalence of orthostatic intolerance on the day of surgery is more than 50% after abdominal surgery. The impact of orthostatic intolerance on ambulation on the day of surgery has been little studied. We investigated orthostatic intolerance and walking ability after colorectal and bariatric surgery in an enhanced recovery programme. METHODS: Eighty-two patients (colorectal: n = 46, bariatric n = 36) were included and analysed in this prospective study. Walk tests for 2 min (2-MWT) and 6 min (6-MWT) were performed before and 24 h after surgery, and 3 h after surgery for 2-MWT. Orthostatic intolerance characterised by presyncopal symptoms when rising was recorded at the same time points. Multivariate binary logistic regressions modelling the probability of orthostatic intolerance and walking inability were performed taking into account potential risk factors. RESULTS: Prevalence of orthostatic intolerance and walking inability was, respectively, 65% and 18% 3-hour after surgery. The day after surgery, patients' performance had greatly improved: approximately 20% of the patients experienced orthostatic intolerance, whilst only 5% of the patients were unable to walk. Adjusted binary logistic regressions demonstrated that age (p = .37), sex (p = .39), BMI (p = .74), duration of anaesthesia (p = .71) and type of surgery (p = .71) did not significantly influence walking ability. CONCLUSION: Our study confirms that orthostatic intolerance was frequent (~ 60%) 3-hour after abdominal surgery but prevented a 2-MWT only in ~20% of patients. No risk factors for orthostatic intolerance and walking inability were evidenced.

Comparison of outcome after right colectomy with an enhanced recovery programme in patients with inflammatory bowel disease and patients operated on for other conditions: a monocentric retrospective study.

PURPOSE: Enhanced recovery programmes (ERPs) after surgery reduce postoperative complications and hospital stay. Patients with inflammatory bowel disease (IBD) often present risk factors for postoperative complications. This accounts for reluctance to include them in ERPs. We compared outcome after right colectomy with an ERP in IBD and non-IBD patients. METHODS: In our GRACE colorectal surgery database comprising 508 patients, we analysed patients scheduled for right colectomy (n = 160). Adherence to the protocol, postoperative complications and length of hospital stay of IBD patients (n = 45) were compared with those of non-IBD patients (n = 115). Data (mean ± SD, median [IQR], count (%)) were compared by Student's t, Mann-Whitney U and chi-square tests when appropriate; p < 0.05 taken as statistically significant. RESULTS: IBD patients were significantly younger (38.9 ± 13.8 vs. 58.9 ± 18.5 years, p < 0.001) and had lower BMI (23.0 ± 5.0 vs. 25.1 ± 5.0 kg m-2, p < 0.01). Adherence to ERP was similar in the two groups. Resumption of eating on the day of the operation was less well tolerated (73.3% vs. 85.2%, p < 0.05) and postoperative pain (p < 0.001) was greater in IBD patients. The incidence of postoperative complications (13.3% vs. 17.3%) and the length of hospital stay (3 [3-4.5] vs. 3 [2-5] days) were comparable in IBD and non-IBD patients, respectively. CONCLUSION: The management of IBD patients in an ERP is not only feasible but also indicated. These patients benefit as much from ERP as non-IBD patients.

Impact of Preoperative Anemia on Outcomes of Enhanced Recovery Program After Colorectal Surgery: A Monocentric Retrospective Study.

BACKGROUND: Anemia is common before major abdominal surgery (35%). It is an independent factor for postoperative complications and longer length of stay (LOS). The aim of this study was to evaluate the extent to which preoperative anemia impacts on enhanced recovery programs (ERP) outcomes. MATERIALS AND METHODS: The data for patients scheduled for colorectal surgery between 2015 and 2019, were analyzed (n = 494). All patients were managed with the same ERP. Demographic data, preoperative risk factors, postoperative complications, LOS and adherence to ERP were compared between anemic and non-anemic patients. Anemia was defined by a hemoglobin concentration < 13 g dL-1 in men and < 12 g dL-1 in women. RESULTS AND DISCUSSION: In total, 173 patients had preoperative anemia. They were older (p < 0.001) and more often male (p = 0.02). The following risk factors were significantly more frequent in the anemic group: renal failure (p = 0.04), malnutrition (p < 0.001), cardiac arrhythmia (p < 0.001), coronaropathy (p = 0.02) and anticoagulant treatment (p < 0.001). Despite more risk factors, anemic patients did not experience more postoperative complications (38.2% vs. 31.2%, p = 0.12). Overall adherence to ERP was similar (18 [16-19] vs. 18 [17-19], p = 0.06). LOS was 4 [3-7] and 3 [2-6.25] days in the anemic and the non-anemic groups, respectively (p < 0.002). Multivariate analysis showed that anemia did not affect LOS (p = 0.27). CONCLUSION: Our study suggests that preoperative anemia does not detract from the benefits of ERP after elective colorectal surgery.

Quadriceps strength in intensive care unit survivors: Variability and influence of preadmission physical activity.

BACKGROUND: Muscle weakness is common in patients who survive a stay in the intensive care unit (ICU). Quadriceps strength (QS) measurement allows evaluation of lower limb performances that are associated with mobility outcomes. OBJECTIVES: The objective of the study was to characterise the range of QS in ICU survivors (ICUS) during their short-term evolution, by comparing them with surgical patients without critical illness and with healthy participants. The secondary aim was to explore whether physical activity before ICU admission influenced QS during that trajectory. METHODS: Patients with length of ICU stay ≥2 days, adults scheduled for elective colorectal surgery, and young healthy volunteers were included. Maximal isometric QS was assessed using a handheld dynamometer and a previously validated standardised protocol. The dominant leg was tested in the supine position. ICUSs were tested in the ICU and 1 month after ICU discharge, while surgical patients were tested before and on the day after surgery, as well as 1 month after discharge. Healthy patients were tested once only. Patients were classified as physically inactive or active before admission from the self-report. RESULTS: Thirty-eight, 32, and 34 participants were included in the ICU, surgical, and healthy groups, respectively. Demographic data were similar in the ICUS and surgical groups. In the ICU, QS was lower in the ICU group than in the surgical and healthy groups (3.01 [1.88-3.48], 3.38 [2.84-4.37], and 5.5 [4.75-6.05] N/kg, respectively). QS did not significantly improve 1 month after ICU discharge, excepted in survivors who were previously physically active (22/38, 56%): the difference between the two time points was -6.6 [-27.1 to -1.7]% vs 20.4 [-3.4 to 43.3]%, respectively, in physically inactive and active patients (p = 0.002). CONCLUSIONS: Patients who survived an ICU stay were weaker than surgical patients. However, a huge QS heterogeneity was observed among them. Their QS did not improve during the month after ICU discharge. Physically inactive patients should be early identified as at risk of poorer recovery.

Bilateral subcostal transversus abdominis plane block does not improve the postoperative analgesia provided by multimodal analgesia after laparoscopic cholecystectomy: A randomised placebo-controlled trial.

BACKGROUND: Laparoscopic cholecystectomy might be considered minor surgery, but it may result in severe postoperative pain. Subcostal transversus abdominis plane (TAP) block, which produces long-lasting supra-umbilical parietal analgesia, might improve analgesia after laparoscopic cholecystectomy. OBJECTIVE: We investigated whether subcostal TAP block would reduce opioid consumption and pain after laparoscopic cholecystectomy in patients provided with multimodal analgesia. DESIGN: A randomised, placebo-controlled, double-blind study. SETTING: The study was conducted at a university teaching hospital from December 2017 to June 2018. PATIENTS: Sixty patients scheduled for laparoscopic cholecystectomy were included. Anaesthesia and postoperative analgesia (etoricoxib, paracetamol, ketamine and dexamethasone) were standardised. INTERVENTION: After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral subcostal TAP block with 20 ml of levobupivacaine 0.375% and epinephrine 5 µg ml or 0.9% saline with epinephrine 5 µg ml. MAIN OUTCOME MEASURES: Opioid consumption in the recovery room and during the first 24 h after surgery were recorded. Postoperative somatic and visceral pain scores, fatigue and nausea were measured. Intra-operative end-tidal concentrations of sevoflurane (FETSEVO) were also recorded. RESULTS: Twenty-four hour postoperative opioid consumption were similar in both groups: 21.2 mg (95% CI 15.3 to 27.1) vs. 25.2 (95% CI 15.1 to 35.5) oral morphine equivalent in the levobupivacaine and 0.9% saline groups, respectively; P = 0.48. No significant between-group differences were observed with regards to parietal (P = 0.56) and visceral (P = 0.50) pain scores, fatigue and nausea. FETSEVO was slightly lower in the levobupivacaine group (P < 0.01). CONCLUSION: Subcostal TAP block does not improve the analgesia provided by multimodal analgesia after laparoscopic cholecystectomy. It allows for a small reduction in intra-operative sevoflurane requirements. TRIAL REGISTRATION: NCT0339153.

How to implement an enhanced recovery programme after colorectal surgery?

INTRODUCTION: Although the concept of enhanced recovery after surgery was introduced more than 20 years ago, its implementation in daily practice still remains difficult. RESULTS: This article addresses bottlenecks and barriers to the development of enhanced recovery programme (ERP). Barriers to the implementation are multifactorial and are raised by the different actors of these programmes: surgeons, anaesthetists, nurses, patients. Solutions and steps that must be respected to succeed in introducing ERP in an hospital are proposed. CONCLUSIONS: Large-scale implementation of ERP continues to face mainly lack of trust and communication. Solutions exist and are based particularly on team work and interdisciplinary collaboration.

Labelling as reference Centre of GRACE (Groupe francophone de Réhabilitation Améliorée après ChirurgiE) for colorectal surgery: its impact on the implementation of enhanced recovery programme at the University Hospital of Liège.

BACKGROUND: Enhanced recovery programme (ERP) has been used in our hospital since 2005 for selected colorectal surgeries. Since October 2015, after labelling as GRACE reference centre, we included all patients scheduled for elective colorectal surgery in this programme. We assessed the impact of our labelling on the implementation of ERP. METHODS: Results of our first 100 patients entered in the GRACE database were analyzed: length of stay, complications, readmission, adherence to the protocol. These results are compared to those of the last 100 patients undergoing colorectal surgery before our labelling. RESULTS: Patients' characteristics in both groups were similar. The complications rate was similar in both groups. The global length of hospital stay was 4 [5] days vs. 8.5 [8] (median [IQR]), respectively after and before labelling; p < .001. The duration of hospitalization for the different subgroups (age, surgical approach, types of surgery) were significantly shorter after our labelling (respectively: p < .001, p < .01, and p < .05). CONCLUSIONS: Our results demonstrate that labelling as reference centre increases the efficiency of the implementation of ERP. The fact that all subgroups of patients benefit from ERP must encourage inclusion of all patients undergoing elective colorectal surgery in ERP.

Quality of life at home and satisfaction of patients after enhanced recovery protocol for colorectal surgery.

BACKGROUND: Quality of life of patients at home after an enhanced recovery protocol (ERP) for surgery has been least studied especially in elderly patients. METHODS: Our first 41 patients entered in the colorectal GRACE database were interviewed through telephone about their postoperative stress, fatigue, pain, difficulty in feeding, home autonomy, and satisfaction. We compared the responses of the elderly patients (>70 years, n = 19) with those of the younger patients. RESULTS: The time between the surgery and the questionnaire was 79 ± 48 days. Early return was experienced as stressful by ±20% of the patients. Fatigue and pain were low (respectively: simple numerical scale [SNS] = 4.2 ± 3.2 and 2.5 ± 2.9). When present, pain was relieved by the prescribed treatment. One-third of the patients described some difficulty in feeding. Fifty percent of the patients felt completely autonomous when returned at home, 80% attributed the rapid recovery of autonomy to the ERP. Finally, 87% were globally satisfied (SNS: 8.5 ± 1.0). The characteristics of the 'elderly' group (77 ± 6 years) and their questionnaire responses were similar to those of the younger patients. CONCLUSIONS: Despite some limitations (retrospective, different time between surgery and the telephone survey), our study suggests that quality of life at home after ERP for colorectal surgery is very satisfactory for over 80% of patients. Furthermore, this study confirms that elderly patients benefit from an ERP for colorectal surgery like younger patients.

Prevalence, characteristics and risk factors of chronic postsurgical pain after laparoscopic colorectal surgery: Retrospective analysis.

BACKGROUND: The prevalence of chronic postsurgical pain (CPSP) is a critical medical problem with economic implications. Its prevalence after gastrointestinal surgery is not well documented, particularly when a laparoscopic approach is used. OBJECTIVE: The aim of the study was to determine the prevalence, the characteristics and the risk factors for CPSP after laparoscopic colorectal surgery. DESIGN: A retrospective analysis using a postal questionnaire. SETTING: The study was conducted at a university teaching hospital. PATIENTS: Patients who underwent laparoscopic colorectal surgery from April 2008 until December 2011 (n = 260). No epidural analgesia was used. MAIN OUTCOME MEASURES: Postoperative pain intensity, incidence and characteristics of CPSP, and impact on quality of life and sleep. RESULTS: Of 199 responses, 33 patients (17%) reported chronic pain at a median [interquartile range, IQR] of 38 [27 to 55] months after laparoscopic surgery with a median intensity of 4 [3 to 5]. CPSP had a negative impact on the quality of life in 84% of patients and on sleep in 43%. CPSP required regular analgesic(s) intake in 54% patients. Using a backward stepwise multivariate logistic regression model, the following variables were determined as independent risk factors for CPSP: redo surgery for anastomotic leakage (P = 0.01), inflammatory bowel disease (IBD) as the indication for surgery (P = 0.01) and preoperative pain (P = 0.05). CONCLUSION: The incidence of CPSP after laparoscopic colorectal surgery (17%) is similar to those reported in the literature after laparotomy. Risk factors are redo surgery for postoperative peritonitis, IBD and preoperative pain. TRIAL REGISTRATION: EudraCT 2012-005712-25.

Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors?

INTRODUCTION: Controlled donation after circulatory death (DCD) remains ethically controversial. The authors developed a controlled DCD protocol in which comfort therapy is regularly used. The aim of this study was to determine whether this policy shortens the DCD donors' life. METHODS: The authors retrospectively analyzed prospectively collected data on patients proposed for DCD at the University Hospital of Liege, Belgium, over a 56-month period. The survival duration of these patients, defined as duration between the time of proposal for DCD and the time of circulatory arrest, was compared between patients who actually donated organs and those who did not. RESULTS: About 128 patients were considered for controlled DCD and 54 (43%) became donors. Among the 74 non-donor patients, 34 (46%) objected to organ donation, 38 patients (51%) were denied by the transplant team for various medical reasons, and two potential DCD donors did not undergo procurement due to logistical and organizational reasons. The survival durations were similar in the DCD donor and non-donor groups. No non-donor patient survived. CONCLUSIONS: Survival of DCD donors is not shortened when compared with non-donor patients. These data support the ethical and respectful approach to potential DCD donors in the authors' center, including regular comfort therapy.