Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION: The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.

Is new ST-segment elevation after coronary artery bypass of clinical importance in the absence of perioperative myocardial infarction?

OBJECTIVE: To determine the frequency and significance of new ST-segment elevation during the early postoperative period after coronary artery bypass grafting (CABG) in patients without enzymatic or electrocardiogram evidence of perioperative myocardial infarction (MI). METHODS: Pre- and early postoperative electrocardiograms were reviewed in 506 patients undergoing CABG in whom MI was excluded by the absence of new Q waves or left bundle branch block and a peak postoperative troponin I less than 10 ng/mL. RESULTS: New ST-segment elevation of 0.1 mV or greater was observed in 64 patients (12.6%). Patients with and without ST-segment elevation did not differ with regard to age, prior coronary artery bypass, number of grafts, use of the internal mammary artery, incidence of postoperative atrial fibrillation, length of stay in the intensive care unit, duration of hospitalization, or 30-day mortality. CONCLUSIONS: ST-segment elevation not due to perioperative MI is common after CABG but is not associated with increased postoperative morbidity or mortality.

Outcomes of care of abdominal aortic aneurysm in Veterans Health Administration facilities: results from the National Surgical Quality Improvement Program.

This report describes outcomes of care for abdominal aortic aneurysms (AAAs), along with methods used by the Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP) in tracking, monitoring, and improving surgical results in VA facilities. Since the inception of NSQIP in 1994, a continual drop in overall surgical mortality, along with decreased morbidity, has occurred. A parallel improvement in results of vascular surgery and AAA repair was also observed. Soon after introduction of endovascular aneurysm repair (EVAR), with Food and Drug Administration device approval in 1999, robust electronic NSQIP records immediately began to capture individual facility performances and outcomes for both types of AAA repair. The NSQIP data center provided actual and risk-adjusted analyses for both procedures semiannually. These analyses have been used by its executive board to provide recommendations, often based on site visits, to improve outcomes. Requirements for reporting of facility-specific data and feedback, paper audits, and site visits appear to relate directly to improved AAA care. Veterans Health Administration (VHA) outcomes of AAA repair are comparable to those reported nationally and internationally and have continued to improve in recent years. National VHA initiatives, based on data feedback and active oversight, relate to some of the lowest AAA mortality rates available. This review describes past, present, and possible future NSQIP strategies to improve outcomes for AAA repair with general comments about recent alternative proposals.

The fundamental law that shapes the United States health care system: is universal health care realistic within the established paradigm?

In this article, the author draws from his own experience as a doctor in describing the issues the uninsured patient population faces. Pointing out that neither the U.S. Constitution nor case law provides a positive right to health care, the author describes the parameters of federal health care funding and ultimately concludes that universal health care cannot be fully achieved in the U.S.

Is there an acceptable answer to rising medical malpractice premiums?

This article explores the key issues involved in the attempts at reform of the present medical malpractice system. Investigating the effects that federal tort reform legislation would have on physicians, patients, lawyers, and the medical malpractice insurers, Dr. Gunnar succinctly outlines the issues surrounding the present "crisis in healthcare" and explores the separate interests involved. The article examines the economic forces influencing the medical malpractice insurance industry, reviews previous tort reform, and predicts the future of federal tort reform legislation. Dr. Gunnar concludes by proposing alternatives for malpractice reform.