RESUMEN
OBJECTIVES: To characterize and quantify accumulating immunologic alterations, pre and postoperatively in patients undergoing elective surgical procedures. BACKGROUND: Elective surgery is an anticipatable, controlled human injury. Although the human response to injury is generally stereotyped, individual variability exists. This makes surgical outcomes less predictable, even after standardized procedures, and may provoke complications in patients unable to compensate for their injury. One potential source of variation is found in immune cell maturation, with phenotypic changes dependent on an individual's unique, lifelong response to environmental antigens. METHODS: We enrolled 248 patients in a prospective trial facilitating comprehensive biospecimen and clinical data collection in patients scheduled to undergo elective surgery. Peripheral blood was collected preoperatively, and immediately on return to the postanesthesia care unit. Postoperative complications that occurred within 30 days after surgery were captured. RESULTS: As this was an elective surgical cohort, outcomes were generally favorable. With a median follow-up of 6 months, the overall survival at 30 days was 100%. However, 20.5% of the cohort experienced a postoperative complication (infection, readmission, or system dysfunction). We identified substantial heterogeneity of immune senescence and terminal differentiation phenotypes in surgical patients. More importantly, phenotypes indicating increased T-cell maturation and senescence were associated with postoperative complications and were evident preoperatively. CONCLUSIONS: The baseline immune repertoire may define an immune signature of resilience to surgical injury and help predict risk for surgical complications.
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Procedimientos Quirúrgicos Electivos , Complicaciones Posoperatorias , Humanos , Estudios Prospectivos , Procedimientos Quirúrgicos Electivos/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Readmisión del Paciente , Recolección de DatosRESUMEN
OBJECTIVE: Human papillomavirus (HPV)-related squamous intraepithelial lesion (SIL) or malignancy is associated with a significantly increased risk of second-site SIL or malignancy. The primary objective of this study was to determine the feasibility and acceptability of concurrent anal, cervical, and vulvovaginal screening in patients with a history of HPV-related gynecologic high-grade SIL or malignancy. The secondary objective was to assess subjects' knowledge regarding HPV screening and risks. METHODS: Women with high-grade cervical, vulvar, or vaginal SIL or malignancy were enrolled during a 1-year pilot period. Subjects with cervical SIL or malignancy underwent vulvar examination and anoscopy. Subjects with vulvovaginal SIL or malignancy underwent Pap test if indicated and anoscopy. Appropriate referrals were made for abnormal findings. Feasibility was assessed by compliance using study acceptance rate, screening procedure adherence, and referral adherence. Acceptability was assessed using a Likert-scaled question after completion of screening procedures. RESULTS: One hundred three women with a diagnosis of high-grade vulvovaginal or cervical SIL or carcinoma were approached regarding study enrollment; of these, 74 (71.8%) enrolled. The median score on the HPV knowledge assessment was 8.1 ± 1.6 (max score 10). Seventy-three (98.6%) of 74 patients rated the screening procedures as acceptable (score of 5/5). On examination, 14 (18.9%) subjects had abnormalities noted; 7 (9.5%) were referred for colorectal surgical evaluation, and 6/7 (85.7%) were compliant with their referral appointments. CONCLUSIONS: Screening examinations for other HPV-related SILs and malignancies, including Pap tests, vulvovaginal inspection, and anoscopy, are acceptable to patients, with abnormal findings in almost 1 in 5 women.
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Carcinoma in Situ , Carcinoma de Células Escamosas , Neoplasias de los Genitales Femeninos , Infecciones por Papillomavirus , Lesiones Intraepiteliales Escamosas , Displasia del Cuello del Útero , Neoplasias del Cuello Uterino , Humanos , Femenino , Virus del Papiloma Humano , Neoplasias del Cuello Uterino/patología , Infecciones por Papillomavirus/complicaciones , Infecciones por Papillomavirus/diagnóstico , Proyectos Piloto , Frotis Vaginal/métodos , Papillomaviridae , Displasia del Cuello del Útero/patología , Carcinoma de Células Escamosas/complicaciones , Lesiones Intraepiteliales Escamosas/complicacionesRESUMEN
OBJECTIVE: To design and establish a prospective biospecimen repository that integrates multi-omics assays with clinical data to study mechanisms of controlled injury and healing. BACKGROUND: Elective surgery is an opportunity to understand both the systemic and focal responses accompanying controlled and well-characterized injury to the human body. The overarching goal of this ongoing project is to define stereotypical responses to surgical injury, with the translational purpose of identifying targetable pathways involved in healing and resilience, and variations indicative of aberrant peri-operative outcomes. METHODS: Clinical data from the electronic medical record combined with large-scale biological data sets derived from blood, urine, fecal matter, and tissue samples are collected prospectively through the peri-operative period on patients undergoing 14 surgeries chosen to represent a range of injury locations and intensities. Specimens are subjected to genomic, transcriptomic, proteomic, and metabolomic assays to describe their genetic, metabolic, immunologic, and microbiome profiles, providing a multidimensional landscape of the human response to injury. RESULTS: The highly multiplexed data generated includes changes in over 28,000 mRNA transcripts, 100 plasma metabolites, 200 urine metabolites, and 400 proteins over the longitudinal course of surgery and recovery. In our initial pilot dataset, we demonstrate the feasibility of collecting high quality multi-omic data at pre- and postoperative time points and are already seeing evidence of physiologic perturbation between timepoints. CONCLUSIONS: This repository allows for longitudinal, state-of-the-art geno-mic, transcriptomic, proteomic, metabolomic, immunologic, and clinical data collection and provides a rich and stable infrastructure on which to fuel further biomedical discovery.
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Biología Computacional , Proteómica , Genómica , Humanos , Metabolómica , Estudios Prospectivos , Proteómica/métodosRESUMEN
BACKGROUND: Sleep disordered breathing (SDB) in typically developing (TD) children is associated with adverse cardiovascular effects. As children with Down syndrome (DS) are at increased risk for SDB, we aimed to compare the cardiovascular effects of SDB in children with DS to those of TD children with and without SDB. METHODS: Forty-four children with DS (3-19 years) were age and sex matched with 44 TD children without SDB (TD-) and with 44 TD children with matched severity of SDB (TD+). Power spectral density was calculated from ECG recordings, for low frequency (LF), high frequency (HF), total power and the LF/HF ratio. RESULTS: Children with DS had lower HF power, and higher LF/HF during sleep and when awake. There were no differences between groups for LF power. SpO2 nadir, average SpO2 drop and SpO2 > 4% drop were larger in the DS group compared to the TD+ group (p < 0.05 for all). CONCLUSIONS: Our findings demonstrate significantly reduced parasympathetic activity (reduced HF power) and increased LF/HF (a measure of sympathovagal balance) in children with DS, together with greater exposure to hypoxia, suggesting SDB has a greater effect in these children that may contribute to an increased risk of adverse cardiovascular outcomes. IMPACT: Sleep disordered breathing in children with Down syndrome exacerbates impaired autonomic control and increases exposure to hypoxia, compared to typically developing children. In typically developing children sleep disordered breathing has adverse effects on autonomic cardiovascular control. The prevalence of sleep disordered breathing is very high in children with Down syndrome; however, studies on the effects on cardiovascular control are limited in this population. This study supports screening and early treatment of sleep disordered breathing in children with Down syndrome.
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Sistema Cardiovascular/fisiopatología , Síndrome de Down/fisiopatología , Síndromes de la Apnea del Sueño/diagnóstico , Adolescente , Presión Sanguínea , Niño , Preescolar , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Adulto JovenRESUMEN
OBJECTIVE: To evaluate the effect of protocol adherence on length of stay (LOS) and recovery-specific outcomes after colectomy. BACKGROUND: Enhanced recovery protocols (ERPs) may decrease postoperative morbidity and LOS; however, the effect of overall protocol adherence remains unclear. METHODS: Using American College of Surgeons' National Surgical Quality Improvement Program colectomy data (July 2014-December 2015) and 13 novel ERP variables, propensity scores were constructed for low (0-5), moderate (6-9), and high adherence (10-13 components). Prolonged LOS (>75th percentile, uncomplicated cases) was modeled with multivariable logistic regression with robust standard errors, adjusted for hospital-level clustering and propensity score. Secondary recovery-specific outcomes were modeled with negative binomial regression. Subgroup analysis was conducted on uncomplicated cases. RESULTS: Among 8139 elective colectomies at 113 hospitals, LOS increased with decreasing adherence (4.3 days [SD 3.3] high adherence vs 7.8 [SD 6.8] low adherence; P < 0.0001). High adherence was associated with fewer complications, including postoperative ileus, compared with moderate (P < 0.0001) and low adherence (P < 0.0001). High-adherence patients achieved recovery milestones earlier (vs low adherence), with return of bowel function at 1.9 (vs 3.7) days, tolerance of diet at 2.4 (vs 5.4) days, and oral pain control at 2.7 (vs 5.0) days (P < 0.0001). Risk-adjusted odds of prolonged LOS were significantly increased for low (odds ratio 2.7, 95% confidence interval 2.0-3.6) and moderate-adherence (odds ratio 1.7, 95% confidence interval 1.4-2.1) groups. In a negative binomial regression, time to recovery was 60% to 95% longer for low versus high adherence (P < 0.0001). CONCLUSIONS: In this large, multi-institutional North American data registry, high adherence to ERPs was associated with earlier recovery, decreased complications, and shorter LOS. ERPs can improve outcomes; however, benefits correlate with adherence.
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Colectomía , Recuperación Mejorada Después de la Cirugía/normas , Adhesión a Directriz/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Protocolos Clínicos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Guías de Práctica Clínica como Asunto , Puntaje de Propensión , Recuperación de la Función , Sistema de Registros , Estudios RetrospectivosRESUMEN
BACKGROUND: Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU. METHODS: A modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines. RESULTS: Consensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period. CONCLUSIONS: Despite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.
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Presión Sanguínea/fisiología , Procedimientos Quirúrgicos Electivos/efectos adversos , Hipertensión/complicaciones , Hipotensión/complicaciones , Complicaciones Posoperatorias/fisiopatología , Antihipertensivos/uso terapéutico , Determinación de la Presión Sanguínea/métodos , Determinación de la Presión Sanguínea/normas , Técnica Delphi , Medicina Basada en la Evidencia/métodos , Humanos , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Hipotensión/diagnóstico , Hipotensión/fisiopatología , Atención Perioperativa/métodos , Atención Perioperativa/normas , Pronóstico , Medición de Riesgo/métodosRESUMEN
OBJECTIVE: Enhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol. METHODS: A retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014-7/27/2016) with comparison to a historical cohort (6/23/2013-9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher's exact, and chi squared tests. RESULTS: One hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates. CONCLUSIONS: ERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.
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Analgésicos Opioides/administración & dosificación , Procedimientos Quirúrgicos Ginecológicos/métodos , Dolor Postoperatorio/tratamiento farmacológico , Estudios de Cohortes , Recuperación Mejorada Después de la Cirugía , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Procedimientos Quirúrgicos Ginecológicos/normas , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Laparoscopía/normas , Dolor Postoperatorio/etiología , Estudios RetrospectivosRESUMEN
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
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Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Posoperatorios/normas , Analgésicos Opioides/efectos adversos , Consenso , Esquema de Medicación , Humanos , Incidencia , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/prevención & control , Manejo del Dolor/efectos adversos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Medición de Riesgo , Factores de Riesgo , Terminología como Asunto , Factores de Tiempo , Resultado del TratamientoRESUMEN
Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes.
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Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Atención Perioperativa/normas , Analgésicos Opioides/efectos adversos , Consenso , Técnica Delphi , Esquema de Medicación , Humanos , Incidencia , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/prevención & control , Manejo del Dolor/efectos adversos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Medición de Riesgo , Factores de Riesgo , Terminología como Asunto , Factores de Tiempo , Resultado del TratamientoRESUMEN
Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
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Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Posoperatorios/normas , Analgésicos Opioides/efectos adversos , Consenso , Técnica Delphi , Esquema de Medicación , Humanos , Incidencia , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/prevención & control , Manejo del Dolor/efectos adversos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Medición de Riesgo , Factores de Riesgo , Terminología como Asunto , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Implementation of enhanced recovery protocols in colectomy reduces length of stay and morbidity, but it remains unknown whether benefits vary by clinical diagnosis. OBJECTIVE: Outcomes after colectomy in the setting of enhanced recovery protocols were compared for 3 diagnoses: 1) neoplasm, 2) diverticulitis, and 3) IBD. DESIGN: This was a retrospective registry-based cohort study. SETTINGS: Novel enhanced recovery variables were released in the American College of Surgeons National Surgical Quality Improvement Program in 2014. PATIENTS: Patients with enhanced recovery variable data undergoing elective colectomy (July 2014 to December 2015) for neoplasm, diverticulitis, or IBD were included. MAIN OUTCOME MEASURES: The primary outcome of interest was prolonged length of stay. Additional outcomes included surgical site infection, death/serious morbidity, reoperation, readmission, and days to achieve per os pain control, tolerance of a diet, and return of bowel function. RESULTS: We identified 4620 patients with neoplasm, 1730 patients with diverticulitis, and 593 patients with IBD. Patients undergoing colectomy for IBD were more likely to have prolonged length of stay (OR, 1.98; 95% CI, 1.46-2.69), death/serious morbidity (OR, 1.62; 95% CI, 1.13-2.32), and readmission (OR, 1.54; 95% CI, 1.15-2.08) compared with patients with neoplasm. Patients with IBD took longer than patients with neoplasm or diverticulitis to achieve per os pain control (mean, 4.2 days vs 3.4 and 3.5 days, p < 0.001) and tolerate a diet (mean, 4.1 days vs 3.7 and 3.5 days, p < 0.001). No statistically significant differences in outcomes between patients with neoplasm and diverticulitis were seen. LIMITATIONS: There may be heterogeneity among implemented enhanced recovery protocols. CONCLUSIONS: Patients undergoing colectomy for neoplasm and diverticulitis have improved outcomes in comparison with patients undergoing colectomy for IBD. Knowledge of expected outcomes for patients with different diagnoses may inform clinician and patient expectations. See Video Abstract at http://links.lww.com/DCR/A623.
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Analgésicos/administración & dosificación , Neoplasias del Colon/cirugía , Diverticulitis del Colon/cirugía , Enfermedades Inflamatorias del Intestino/cirugía , Tiempo de Internación/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Infección de la Herida Quirúrgica/epidemiología , Administración Oral , Adulto , Anciano , Protocolos Clínicos , Estudios de Cohortes , Colectomía/métodos , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Ileostomía , Masculino , Persona de Mediana Edad , Mortalidad , Readmisión del Paciente , Atención Perioperativa/métodos , Complicaciones Posoperatorias/epidemiología , Pronóstico , Recuperación de la Función , Reoperación , Estudios RetrospectivosRESUMEN
As the population ages, the increasing surgical volume and complexity of care are expected to place additional care delivery burdens in the perioperative setting. In this age of integrated multidisciplinary care of the surgical patients, there is increasing recognition that an evidence-based perioperative pathway is associated with the optimal outcomes. These pathways, collectively referred to as Enhanced Recovery Pathways, have resulted in shortened length of hospital stay, reduced complications, and variance in outcomes, as well as earlier return to baseline activities. The American Society for Enhanced Recovery (ASER) is a multispecialty, nonprofit international organization, dedicated to the practice of enhanced recovery in perioperative patients through education and research. Perioperative Quality Initiatives were formed whose intent is to organize a series of consensus conferences on topics of interest related to perioperative medicine. The journal affiliation between American Society for Enhanced Recovery and Anesthesia & Analgesia will enable these evidence-based practices to be disseminated widely and swiftly to the practicing perioperative health care professionals so they can be adopted to improve the quality of perioperative surgical care.
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Medicina Basada en la Evidencia/tendencias , Atención Perioperativa/tendencias , Recuperación de la Función/fisiología , Sociedades Médicas/tendencias , Medicina Basada en la Evidencia/métodos , Humanos , Atención Perioperativa/métodos , Estados UnidosRESUMEN
Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.
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Consenso , Estado Nutricional/fisiología , Atención Perioperativa/normas , Investigación Cualitativa , Recuperación de la Función/fisiología , Sociedades Médicas/normas , Ayuno/fisiología , Humanos , Atención Perioperativa/tendencias , Sociedades Médicas/tendencias , Estados UnidosRESUMEN
Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2-3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care.
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Consenso , Medición de Resultados Informados por el Paciente , Atención Perioperativa/tendencias , Calidad de la Atención de Salud/tendencias , Recuperación de la Función/fisiología , Sociedades Médicas/tendencias , Humanos , Atención Perioperativa/normas , Calidad de la Atención de Salud/normas , Calidad de Vida/psicología , Sociedades Médicas/normasRESUMEN
The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.
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Cirugía Colorrectal/tendencias , Enfermedades Gastrointestinales/epidemiología , Atención Perioperativa/normas , Complicaciones Posoperatorias/epidemiología , Recuperación de la Función/fisiología , Sociedades Médicas/normas , Cirugía Colorrectal/efectos adversos , Consenso , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Quirúrgicos Electivos/tendencias , Enfermedades Gastrointestinales/prevención & control , Humanos , Atención Perioperativa/métodos , Complicaciones Posoperatorias/prevención & control , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: To study current perioperative fluid administration and associated outcomes in common surgical cohorts in the United States. BACKGROUND: An element of enhanced recovery care protocols, optimized perioperative fluid administration may be associated with improved outcomes; however, there is currently no consensus in the United States on fluid use or the effects on outcomes of this use. METHODS: The study included all inpatients receiving colon, rectal, or primary hip or knee surgery, 18 years of age or older, who were discharged from a hospital between January 1, 2008 and June, 30 2012 in the Premier Research Database. Patient outcomes and intravenous fluid utilization on the day of surgery were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low day-of-surgery fluids with the likelihood of increased hospital length of stay (LOS), total costs, or postoperative ileus. RESULTS: The study showed significant associations between high fluid volume given on the day of surgery with both increased LOS (odds ratio 1.10-1.40) and increased total costs (odds ratio 1.10-1.50). High fluid utilization was associated with increased presence of postoperative ileus for both rectal and colon surgery patients. Low fluid utilization was also associated with worse outcomes. CONCLUSIONS: According to results from this review of current practice in US hospitals, fluid optimization would likely lead to decreased variability and improved outcomes.
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Fluidoterapia/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud , Pautas de la Práctica en Medicina/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECTIVE: To examine the impact of alvimopan on outcomes and costs in a rigorous enhanced recovery colorectal surgery protocol. BACKGROUND: Postoperative ileus remains a major source of morbidity and costs in colorectal surgery. Alvimopan has been shown to reduce incidence of postoperative ileus in enhanced recovery colorectal surgery; however, data are equivocal regarding its benefit in reducing length of stay and costs. METHODS: Patients undergoing major elective enhanced recovery colorectal surgery were identified from a prospectively-collected database (2010-2013). Multivariable analyses were employed to compare outcomes and hospital costs among patients who had alvimopan versus no alvimopan by adjusting for demographic, clinical, and treatment characteristics. RESULTS: A total of 660 patients were included; 197 patients received alvimopan and 463 patients had no alvimopan. In unadjusted analysis, the alvimopan group had a faster return of bowel function, shorter length of stay, and lower rates of ileus, Foley re-insertion, and urinary tract infection (all Pâ<â0.01). After adjustment, alvimopan was associated with a faster return of bowel function by 0.6 day (Pâ=â0.0006), and lower incidence of postoperative ileus (odds ratio 0.23, Pâ=â0.0002). With adjustment, alvimopan was associated with a shorter length of stay by 1.6 days (Pâ=â0.002), and a hospital cost savings of $1492 per patient (Pâ=â0.01). CONCLUSIONS: Alvimopan administration as an element of enhanced recovery colorectal surgery is associated with faster return of bowel function, lower incidence of postoperative ileus, shorter hospitalization, and a significant cost savings. These results suggest that alvimopan is cost-effective in the setting of enhanced recovery colorectal surgery protocols, and should therefore be considered in these programs.
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Cirugía Colorrectal/economía , Ahorro de Costo/economía , Fármacos Gastrointestinales/administración & dosificación , Fármacos Gastrointestinales/economía , Ileus/prevención & control , Laparoscopía/economía , Piperidinas/administración & dosificación , Piperidinas/economía , Adulto , Anciano , Índice de Masa Corporal , Análisis Costo-Beneficio , Femenino , Costos de Hospital , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recuperación de la Función , Factores de Riesgo , Estados UnidosRESUMEN
The diagnosis of stage IV colorectal cancer was once associated with a uniformly grim prognosis. Over the last 20 years, advances in chemotherapeutics, surgical technique, and surgical adjuncts have dramatically broadened treatment options and improved outcomes. Among current treatment options, surgery remains the key component of any multidisciplinary approach with surgical data demonstrating the longest survivorship. This review will summarize current and developing surgical advances in the treatment of metastatic colorectal cancer. Specifically, we will discuss how surgical interventions fit within the greater context of a multi-modality approach, as well as, the specific, recent innovations in the surgical management of hepatic and extrahepatic metastases.
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Neoplasias Colorrectales/terapia , Terapia Combinada/métodos , Neoplasias Hepáticas/terapia , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/secundario , Estadificación de Neoplasias , Selección de Paciente , Pronóstico , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE: To identify differences in hospital course and hospitalization cost when comparing image-guided percutaneous drainage with surgical repair for gastrointestinal anastomotic leaks. MATERIALS AND METHODS: A retrospective IRB-approved search using key words "leak" and/or "anastomotic" was performed on all adult CT reports from 2002 to 2011. CT examinations were reviewed for evidence of a postoperative gastrointestinal leak and assigned a confidence score of 1-5 (1 = no leak, 5 = definite leak). Patients with an average confidence score <4 were excluded. Type of surgery, patient data, method of leak management, number of hospital admissions, length of hospital stay, discharge disposition, number of CT examinations, number of drains, and hospitalization costs were collected. RESULTS: One hundred thirty-nine patients had radiographic evidence of a gastrointestinal anastomotic leak (esophageal, gastric, small bowel or colonic). Nine patients were excluded due to low confidence scores. Twenty-seven patients underwent surgical repair (Group A) and 103 were managed entirely with percutaneous image-guided drainage (Group B). There was no significant difference in patient demographics or number of hospital admissions. Patients in Group A had longer median hospital stays compared to Group B (48 vs. 32 days, p = 0.007). The median total hospitalization cost for Group A was more than twice that for Group B ($99,995 vs. $47,838, p = 0.001). Differences in hospital disposition, number of CT examinations, number of drains, and time between original surgery and first CT examination were statistically significant. CONCLUSION: Gastrointestinal anastomotic leaks managed by percutaneous drainage are associated with lower hospital cost and shorter hospital stays compared with surgical management.
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Fuga Anastomótica/terapia , Drenaje/métodos , Tracto Gastrointestinal/cirugía , Hospitalización , Adulto , Anciano , Fuga Anastomótica/cirugía , Femenino , Hospitalización/economía , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Cirugía Asistida por Computador , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS: One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250-mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS: Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016). CONCLUSIONS: The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.