Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines.

OBJECTIVE: This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines. BACKGROUND: ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy. METHODS: We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated. RESULTS: Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery. CONCLUSIONS: ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.

PFAS adsorbent selection: The role of adsorbent use rate, water quality, and cost.

Per- and polyfluoroalkyl substance (PFAS) contamination in aqueous matrices has intensified the search for PFAS adsorbents with elevated capacity, selectivity, and cost effectiveness. A novel surface modified organoclay (SMC) adsorbent was evaluated for PFAS removal performance in parallel with granular activated carbon (GAC) and ion exchange resin (IX) for the treatment of five distinct PFAS impaired waters including groundwater, landfill leachate, membrane concentrate and wastewater effluent. Rapid small scale column tests (RSSCTs) and breakthrough modeling were coupled to provide insight on adsorbent performance and cost for multiple PFAS and water types. IX exhibited the best performance with respect to adsorbent use rates in treatment of all tested waters. IX was nearly four times more effective than GAC and two times more effective than SMC in the treatment of PFOA from water types excluding groundwater. Employed modeling strengthened the comparison of adsorbent performance and water quality to infer adsorption feasibility. Further, evaluation of adsorption was extended beyond PFAS breakthrough with the inclusion of unit adsorbent cost as a decision metric influencing adsorbent selection. An analysis of levelized media cost indicated treatment of landfill leachate and membrane concentrate was at least three times more expensive than groundwaters or wastewaters evaluated.

Individual risk modelling for esophagectomy: a systematic review.

INTRODUCTION: A number of models have been applied to predict outcomes from esophagectomy. This systematic review aimed to compare their clinical credibility, methodological quality and performance. METHODS: A systematic review of the PubMed, EMBASE and Cochrane databases was performed in October 2012. Model and study quality were appraised using the framework of Minne et al. RESULTS: Twenty studies were included in total; these were heterogeneous, retrospective and conducted over a number of years; all models were generated via logistic regression. Overall mortality was high, and consequently not representative of current practice. Clinical credibility and methodological quality were variable, with frequent failure to perform internal validation and variable presentation of calibration and discrimination metrics. P-POSSUM demonstrated the best calibration and discrimination for predicting mortality. Other than the Southampton score (which has yet to be externally validated) and the Amsterdam score, no studies had utility in predicting complications. CONCLUSION: Whilst a number of models have been developed, adapted or trialled, due to numerous limitations, larger and more contemporary studies are required to develop and validate models further. The role of alternative techniques such as decision tree analysis and artificial neural networks is not known.