Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature.

Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.

Parallels between our response to COVID-19 and approach to patient safety.

The response to the COVID-19 pandemic and the approach to patient safety share three important concepts: the challenges of preventing rare events, use of rules, and tolerance for uncertainty. We discuss how each of these ideas can be utilised in perioperative safety to create a high-reliability system.

Epidural anesthesia may be associated with increased postoperative complications in the elderly population undergoing radical cystectomy: an analysis from the National Surgical Quality Improvement Project (NSQIP) database.

BACKGROUND: Epidural anesthesia has been associated with a decrease in cardiopulmonary complications and a decrease in blood loss in orthopedic procedures. Its influence on the outcomes of patients receiving radical cystectomies is unknown. We aim to use the large national database from the National Surgical Quality Improvement Project (NSQIP) to examine whether postoperative complications may be affected by the use of epidural anesthesia during radical cystectomy. METHODS: Data were collected from the 2014-2016 participant user files of the NSQIP database. Patients receiving radical cystectomy were identified by CPT code and further stratified by anesthesia type. Demographics, length of stay, and 30-day complications including death were collected and analyzed using univariable and multivariable analysis. RESULTS: A total of 6448 patients met the inclusion criteria for analysis. Between 2014 and 2016, 5064 patients received general anesthesia only (GA) and 1384 patients received general and epidural anesthesia (GEA). Statistical analysis showed an overall increase in major complications (17.8% vs 18.5%) in the GEA group (p = 0.0046). Subgroup analysis showed major complications to be more likely in patients older than 75 years receiving GEA instead of GA (p = 0.0301). CONCLUSIONS: Elderly patients (age > 75) undergoing radical cystectomy may experience more major complications with the use of epidural anesthesia. This may be due to end-organ effects from the hemodynamic changes of epidural anesthesia which are poorly tolerated in the elderly population. Further single intervention epidural studies need to be performed to isolate the effects of epidural anesthesia on individual surgical procedures.

Epidural analgesia for hepatopancreatobiliary operations and postoperative urinary tract infections: an unrecognized association of "best-practices" and adverse outcomes.

BACKGROUND: Thoracic epidural analgesia (TEA) is considered "best-practices" for pain-control following HPB operations. It is unknown if TEA increases the risk of UTI. We sought to examine the association of TEA and UTI following HPB operations. METHODS: A retrospective cohort study of patients undergoing elective HPB operations was performed (ACS-NSQIP [2014-2016]). Patients were categorized by TEA utilization. The primary outcome was UTI. Multivariable logistic regression models were created to examine the association of TEA with UTI; including sensitivity and interaction analyses for age and gender. RESULTS: Among 28,571 patients included, 5764 (20.2%) had TEA. UTI occurred more frequently with TEA (3.5% vs. 2.2%, p < 0.01). After multivariable analysis, TEA was associated with increased risk of UTI (1.59 [1.34-1.89]); when stratified by age and gender, the association persisted with an incremental increased risk observed in males over 70 years (1.91 [1.41-2.59]). UTI was associated with increased risk of sepsis (16.8% vs. 5.6%, P < 0.001), LOS (9 versus 6 days, P < 0.001) and readmission rates (21.4% vs. 12.3%, P < 0.001). CONCLUSION: Despite TEA recommended as a best-practice standard for HPB operations, the increased risk of UTI calls for evaluation of current practices and consideration of alternative strategies for high-risk vulnerable populations - elderly males.

The Intersection of Regional Anesthesia and Cancer Progression: A Theoretical Framework.

The surgical stress and inflammatory response and volatile anesthetic agents have been shown to promote tumor metastasis in animal and in-vitro studies. Regional neuraxial anesthesia protects against these effects by decreasing the surgical stress and inflammatory response and associated changes in immune function in animals. However, evidence of a similar effect in humans remains equivocal due to the high variability and retrospective nature of clinical studies and difficulty in directly comparing regional versus general anesthesia in humans. We propose a theoretical framework to address the question of regional anesthesia as protective against metastasis.This theoretical construct views the immune system, circulating tumor cells, micrometastases, and inflammatory mediators as distinct populations in a highly connected system. In ecological theory, highly connected populations demonstrate more resilience to local perturbations but are prone to system-wide shifts compared with their poorly connected counterparts. Neuraxial anesthesia transforms the otherwise system-wide perturbations of the surgical stress and inflammatory response and volatile anesthesia into a comparatively local perturbation to which the system is more resilient. We propose this framework for experimental and mathematical models to help determine the impact of anesthetic choice on recurrence and metastasis and create therapeutic strategies to improve cancer outcomes after surgery.

Perioperative Outcomes of Melanoma Patients Undergoing Surgery After Receiving Immunotherapy or Targeted Therapy.

BACKGROUND: Traditional chemotherapy agents adversely affect wound healing and need to be held prior to or after surgery. Immune checkpoint inhibitors (ICIs) and targeted agents are now standard of care for the several treatment cancers. We hypothesize that ICI and targeted therapy do not have similar adverse effects on perioperative outcomes. METHODS: We performed a review of melanoma patients undergoing surgery at an academic hospital between 2011 and 2019. All patients received ICI or targeted therapy ≤ 60 days prior to surgery, including palliative procedures. Preoperative performance status was assessed using Eastern Cooperative Oncology Group score and American Society of Anesthesiologists Classification System. Thirty-day complications were classified by Clavien-Dindo grade. No statistical comparisons were performed. RESULTS: Of 63 patients included in the analysis, 29 (46%) patients received ICI and 34 (54%) received targeted therapy with median of 14 days (IQR 5-27 days) between the last preoperative dose and day of surgery (ICI, median 18 days [IQR 13-34.5]; targeted therapy, median 7 days [IQR 3-22.25]). There were no perioperative mortalities. Among patients treated with ICI, 22 patients (76%) had no complications. Four patients had wound infections (2 readmitted), 1 had reoperation (hematoma) and 2 readmitted for other reasons (fever; volvulus). Among patients treated with targeted therapy, 25 patients (74%) had no complications. Seven patients had wound infections (none readmitted), 1 had reoperation (flap failure) and 1 had dehiscence (not treated). CONCLUSIONS: Patients undergoing treatment with ICI or targeted therapies can safely undergo surgery without substantially increased risk of serious intraoperative and postoperative complications.

Perioperative Anemia: Prevention, Diagnosis, and Management Throughout the Spectrum of Perioperative Care.

Anemia is common in the perioperative period and is associated with poor patient outcomes. Remarkably, anemia is frequently ignored until hemoglobin levels drop low enough to warrant a red blood cell transfusion. This simplified transfusion-based approach has unfortunately shifted clinical focus away from strategies to adequately prevent, diagnose, and treat anemia through direct management of the underlying cause(s). While recommendations have been published for the treatment of anemia before elective surgery, information regarding the design and implementation of evidence-based anemia management strategies is sparse. Moreover, anemia is not solely a concern of the preoperative encounter. Rather, anemia must be actively addressed throughout the perioperative spectrum of patient care. This article provides practical information regarding the implementation of anemia management strategies in surgical patients throughout the perioperative period. This includes evidence-based recommendations for the prevention, diagnosis, and treatment of anemia, including the utility of iron supplementation and erythropoiesis-stimulating agents (ESAs).

Enhanced REVENUE After Surgery? A Cost-Standardized Enhanced Recovery Pathway for Mastectomy Decreases Length of Stay.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been shown to improve surgical, anesthetic, and economic outcomes in intermediate-to-high-risk surgeries. Its influence on length of stay and cost of low-risk surgeries has yet to be robustly studied. As value-based patient care comes to the forefront of anesthesiology research, the focus shifts to strategies that maintain quality while effectively containing cost. METHODS: In July 2016, we implemented an ERAS for mastectomy protocol consisting of limiting fasting state, preoperative multimodal analgesia, and pectoralis I and II blocks. After 1 year, patient records were retrospectively reviewed for length of stay, opioid consumption, pain scores, and hospital charges. RESULTS: Implementation of an ERAS protocol for mastectomies led to a decrease in opioid consumption, and statistically significant decrease in length of stay (1.19 vs. 1.44, p = 0.01). No significant change in hospital charges was observed ($25,787 vs. $25,863, p = 0.97); however, the variance of charges was significantly decreased (6.8 × 107 vs. 1.5 × 108, p = 0.002). The decrease in length of stay translated to an extra 100 hospital bed days which can provide up to an additional $2,100,000 in gross patient service revenue from additional mastectomy volume. CONCLUSION: ERAS protocols for mastectomies may prove beneficial by allowing growing hospitals to increase bed capacity and consequently surgical volume. Despite no change in hospital charges, we predict a potential increase in gross patient service revenue of $2.1 million due to saved hospital bed days.

Improved Outcomes of Enhanced Recovery After Surgery (ERAS) Protocol for Radical Cystectomy with Addition of a Multidisciplinary Care Process in a US Comprehensive Cancer Care Center.

INTRODUCTION: Although enhanced recovery after surgery (ERAS) components include both anesthesia and surgical care processes, it is unclear whether a multidisciplinary approach to implementing ERAS care processes improves clinical outcomes. The addition of multidisciplinary care with anesthesiology-related components to an existing ERAS protocol for radical cystectomy at a US comprehensive cancer center provided an opportunity to compare short- and long-term outcomes. METHODS: We retrospectively compared the outcomes of 116 consecutive patients who underwent cystectomy after implementation of a multidisciplinary ERAS protocol with those of a historical control group of 143 consecutive patients who had been treated with a surgical ERAS protocol. Length of stay, return of bowel function, rate of blood transfusion, nausea, pain, and readmission rates were examined. RESULTS: Implementation of a multidisciplinary ERAS protocol was associated with better postsurgical symptom control, as indicated by lower rates of patient-reported nausea (P < .05). Multivariate Poisson regression analysis showed a decrease in estimated intraoperative transfusions (P ≤ .001) after adjusting for the effects of potential confounding variables. There were no statistically significant differences noted in length of stay, return of bowel function, 30- and 90-day complications, or readmissions. CONCLUSION: This is the first study to investigate the effects of adding anesthesia ERAS components to an existing surgical ERAS protocol for radical cystectomy. We found that with the addition of anesthesia-related interventions, there was a decrease in transfusions and nausea.

Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center.

BACKGROUND: The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. METHODS: We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. RESULTS: Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses. CONCLUSIONS: Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

A novel approach to improving efficiency and cost saving in preoperative blood preparation.

BACKGROUND: Preoperative ordering of blood products has been an area of optimization due to considerable variability among physicians; overpreparation can lead to extra costs and underpreparation of blood can potentially compromise patient safety. STUDY DESIGN AND METHODS: We examined the potential cost savings of extending the storage interval of a presurgical type-and-screen sample from 7 to 14 days, thereby reducing the need for a new specimen on the day of surgery. RESULTS: Sensitivity analysis showed annual cost savings for our institution to be an estimated $38,770 ($22,420-$73,120). CONCLUSION: These results are even more robust when incorporating the additional potential savings from improved operating room efficiency.

Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations.

The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.

Preoperative immunonutrition and carbohydrate loading associated with improved bowel function after radical cystectomy.

BACKGROUND: Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery. Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. METHODS: A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). RESULTS: The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups. CONCLUSIONS: Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.

Preoperative nutrition-enhanced recovery after surgery protocol for thoracic neoplasms.

OBJECTIVES: Because patients' preoperative nutritional status influences the outcomes, we have used a preoperative nutrition program for surgical patients for a 2-year period and compared the results with those from a cohort treated in the previous 2 years. METHODS: We retrospectively reviewed curative thoracic neoplasm resections from July 15, 2016, to July 15, 2018, in patients who had received a preoperative nutritional-enhanced recovery after surgery (N-ERAS) protocol. The protocol consisted of 5 days of an oral immunonutrition drink 3 times daily, daily receipt of probiotics, and a carbohydrate-loading drink the night before surgery. The historical control cohort (standard group) included those patients who had undergone surgery by the same surgeon during the previous 24 months. We excluded patients who had undergone esophageal, diagnostic, benign, emergency, or palliative procedures. Nonparametric and parametric statistical tests were used to analyze the data. RESULTS: The data from 462 patients were analyzed: 229 N-ERAS patients and 233 standard patients. No significant demographic or caseload differences were found between the 2 groups. The major significant outcome differences included fewer postoperative complications (30 [13.1%] in the N-ERAS group vs 60 [25.8%] in the standard group; P < .001) and shorter hospital stays (3.8 ± 1.9 days for the N-ERAS group vs 4.4 ± 2.6 days for the standard group; P = .001). Use of the N-ERAS protocol resulted in a 16% reduction ($2198; P < .001) in the mean direct hospital costs/patient. Consequently, for the N-ERAS cohort, the hospital was likely saved $503,342 during the 2-year period for the 229 patients just by using the N-ERAS protocol. CONCLUSIONS: Thoracic surgeons should consider using the nontoxic, patient-compliant N-ERAS protocol for their patients, with an expectation of improved clinical results at lower hospital costs-an important consideration when exploring methods to decrease costs because hospitals are increasingly being paid by a negotiated prospective bundled payment reimbursement model.

Prevalence of Preoperative Iron Deficiency Anemia: A Case Series Among Patients Undergoing Radical Cystectomy.

Anemia occurs in a significant group of patients with bladder cancer before radical cystectomy. Iron deficiency is a readily identifiable cause of anemia, which can be treated before surgery. The proportion of patients with bladder cancer with iron deficiency anemia is unknown. Laboratory and clinical outcomes were collected on 47 consecutive patients presenting for radical cystectomy. Iron studies found 30% of patients had iron deficiency anemia. These findings present an opportunity to treat anemia before surgery, to reduce blood transfusions during radical cystectomy.