How can lean thinking improve ERAS program in bariatric surgery?

INTRODUCTION: Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols. METHODS: Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time. RESULTS: 471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008). CONCLUSION: This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

Colorectal Cancer Early Detection in Stool Samples Tracing CpG Islands Methylation Alterations Affecting Gene Expression.

Colorectal cancer (CRC) is a major cause of cancer mortality. Early diagnosis is relevant for its prevention and treatment. Since DNA methylation alterations are early events in tumourigenesis and can be detected in cell-free DNA, they represent promising biomarkers for early CRC diagnosis through non-invasive methods. In our previous work, we identified 74 early altered CpG islands (CGIs) associated with genes involved in cell cross-talking and cell signalling pathways. The aim of this work was to test whether methylation-based biomarkers could be detected in non-invasive matrices. Our results confirmed methylation alterations of GRIA4 and VIPR2 in CRC tissues, using MethyLight, as well as in stool samples, using a much more sensitive technique as droplet digital PCR. Furthermore, we analysed expression levels of selected genes whose promoter CGIs were hypermethylated in CRC, detecting downregulation at mRNA and protein levels in CRC tissue for GRIA4, VIPR2, SPOCK1 and SLC6A3. Most of these genes were already lowly expressed in colon normal tissues supporting the idea that cancer DNA methylation targets genes already barely expressed in the matched normal tissues. Our study suggests GRIA4 and VIPR2 as biomarkers for early CRC diagnosis using stool samples and confirms downregulation of genes hypermethylated in CRC.

Colorectal cancer early methylation alterations affect the crosstalk between cell and surrounding environment, tracing a biomarker signature specific for this tumor.

Colorectal cancer (CRC) develops through the accumulation of both genetic and epigenetic alterations. However, while the former are already used as prognostic and predictive biomarkers, the latter are less well characterized. Here, performing global methylation analysis on both CRCs and adenomas by Illumina Infinium HumanMethylation450 Bead Chips, we identified a panel of 74 altered CpG islands, demonstrating that the earliest methylation alterations affect genes coding for proteins involved in the crosstalk between cell and surrounding environment. The panel discriminates CRCs and adenomas from peritumoral and normal mucosa with very high specificity (100%) and sensitivity (99.9%). Interestingly, over 70% of the hypermethylated islands resulted in downregulation of gene expression. To establish the possible usefulness of these non-invasive markers for detection of colon cancer, we selected three biomarkers and identified the presence of altered methylation in stool DNA and plasma cell-free circulating DNA from CRC patients.