Patient-reported outcomes after oncologic hepatic resection predict the risk of delayed readiness to return to intended oncologic therapy (RIOT).

BACKGROUND: Optimal surgical recovery is critical to readiness to return to intended oncologic therapy (RIOT). The current study defined the value of patient-reported outcomes (PROs) in predicting the risk for delayed RIOT after oncologic hepatic resection. METHODS: In a prospective longitudinal study, perioperative symptoms were assessed using a valid PRO assessment tool, the MD Anderson Symptom Inventory module for hepatectomy perioperative care (MDASI-PeriOp-Hep), for 4 weeks after surgery. The timed up and go test (TUGT) was administered before surgery, by discharge day, and at the first postoperative follow-up visit. Multivariate logistic regression analysis assessed the predictive value of PROs for delayed RIOT. RESULTS: We enrolled 210 patients and analyzed 148 patients who received adjuvant chemotherapy and contributed more than 3 PRO assessments postoperatively. About 36 percent of the patients had delayed RIOT (>5 weeks, range 1-14 weeks). MDASI scores for drowsiness, fatigue, dry mouth, and interference with general activity, walking, and work on day 7 after discharge and MDASI scores for incisional tightness, fatigue, dry mouth, shortness of breath, and interference with work on day 14 after discharge were associated with delayed RIOT (all P < 0.05). Walking and general activity items on the MDASI-Interference subscale on day 7 after discharge were highly correlated with prolonged TUGT scores at discharge (P < 0.01). CONCLUSION: We defined clinically meaningful PROs on MDASI-PeriOp-Hep after hepatic resection that predicted increased risk of delayed RIOT. These findings highlight the importance PROs for monitoring symptoms and functioning 1-2 weeks after discharge to be implementing into perioperative care.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness.

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

Laparoscopic transverse abdominis plane block: how I do it and a cost efficiency analysis.

PURPOSE: To determine the efficacy and efficiency of laparoscopic transverse abdominis plane block (Lap-TAP) in patients undergoing pancreatoduodenectomy and gastrectomy compared to those of ultrasound-guided TAP (US-TAP). METHODS: We retrospectively analyzed the records of patients who underwent open or minimally invasive (MIS) pancreatoduodenectomy and major gastrectomy with the use of Lap-TAP or US-TAP at our institution between November 1, 2018, and September 30, 2021. We compared the estimated time and cost associated with Lap-TAP and US-TAP. We also compared postoperative opioid use and pain scores between patients who underwent open laparotomy with these TAPs. RESULTS: A total of 194 patients were included. Overall, 114 patients (59%) underwent pancreatectomy, and 80 patients (41%) underwent gastrectomy. Additionally, 138 patients (71%) underwent an open procedure, and 56 patients (29%) underwent MIS. A total of 102 patients (53%) underwent US-TAP, and 92 (47%) underwent Lap-TAP. The median time to skin incision was significantly shorter in the Lap-TAP group (US-TAP, 59 min vs. Lap-TAP, 45 min; P < 0.001), resulting in an estimated reduction in operation cost by $602. Pain scores and postoperative opioid use were similar between Lap-TAP and US-TAP among open surgery patients, indicating equivalent pain control between Lap-TAP and US-TAP. CONCLUSION: Lap-TAP was equally effective in pain control as US-TAP after pancreatectomy and gastrectomy, and Lap-TAP can reduce operation time and cost. Lap-TAP is considered the preferred approach for MIS pancreatectomy and gastrectomy, which occasionally needs conversion to laparotomy.

Utility of Patient-Reported Symptom and Functional Outcomes to Indicate Recovery after First 90 Days of Radical Cystectomy: A Longitudinal Study.

This is a longitudinal prospective study that tracked multiple symptom burden and functioning status for bladder cancer (BLC) patients for 3 months post-radical cystectomy at The University of Texas MD Anderson Cancer Center, using a validated disease-specific patient-reported outcome measure (PROM) tool, the MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). The feasibility of collecting an objective measure for physical functioning, using "Timed Up & Go test" (TUGT) and PRO scores at baseline, discharge and end of study, was tested. Patients (n = 52) received care under an ERAS pathway. The more severe scores of fatigue, sleep disturbance, distress, drowsiness, frequent urination and urinary urgency at baseline predicted poor functional recovery postoperatively (OR = 1.661, 1.039-2.655, p = 0.034); other more severe symptoms at discharge (pain, fatigue, sleep disturbance, lack of appetite, drowsiness, bloating/abdominal tightness) predicted poor functional recovery (OR = 1.697, 1.114-2.584, p = 0.014) postoperatively. Compliance rates at preoperative, discharge and end of study were 100%, 79% and 77%, while TUGT completion rates were 88%, 54% and 13%, respectively. This prospective study found that more severe symptom burden at baseline and discharge is associated with poor functional recovery post-radical cystectomy for BLC. The collection of PROs is more feasible than using performance measures (TUGT) of function following radical cystectomy.

Review of cancer therapies for the perioperative physician.

Advances in cancer treatments over the past decades combining chemotherapy with novel technologies in immunotherapies, radiation therapies, and interventional radiology have prolonged life expectancy. Patients have more options for treatments of their primary or metastatic diseases. Increased procedural techniques amid an aging population with multiple comorbidities present risks and challenges in the perioperative period.Chemotherapy remains the mainstay of cancer treatment, can be given intraoperatively, and is combined with other treatment modalities. Immunotherapy is particular to cancer cells while being less toxic to healthy cells. Cancer vaccines stimulate the immune system to stop disease progression. Oncolytic viruses enhance the immune system's cytotoxic effect and show promise to halt metastatic disease progression if present in the perioperative period. Novel techniques in radiation therapy combined with traditional treatments show enhanced survival. This review focuses on current cancer treatments encountered in the perioperative period.

Development and implementation of an institutional enhanced recovery program data process.

Background: With increasing implementation of enhanced recovery programs (ERPs) in clinical practice, standardised data collection and reporting have become critical in addressing the heterogeneity of metrics used for reporting outcomes. Opportunities exist to leverage electronic health record (EHR) systems to collect, analyse, and disseminate ERP data. Objectives: (i) To consolidate relevant ERP variables into a singular data universe; (ii) To create an accessible and intuitive query tool for rapid data retrieval. Method: We reviewed nine established individual team databases to identify common variables to create one standard ERP data dictionary. To address data automation, we used a third-party business intelligence tool to map identified variables within the EHR system, consolidating variables into a single ERP universe. To determine efficacy, we compared times for four experienced research coordinators to use manual, five-universe, and ERP Universe processes to retrieve ERP data for 10 randomly selected surgery patients. Results: The total times to process data variables for all 10 patients for the manual, five universe, and ERP Universe processes were 510, 111, and 76 min, respectively. Shifting from the five-universe or manual process to the ERP Universe resulted in decreases in time of 32% and 85%, respectively. Conclusion: The ERP Universe improves time spent collecting, analysing, and reporting ERP elements without increasing operational costs or interrupting workflow. Implications: Manual data abstraction places significant burden on resources. The creation of a singular instrument dedicated to ERP data abstraction greatly increases the efficiency in which clinicians and supporting staff can query adherence to an ERP protocol.

Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy.

BACKGROUND: Minimally invasive, robotic gastrectomy is associated with better short-term outcomes and quicker functional recovery. However, the degree to which the robotic approach influences postoperative pain and opioid use after gastrectomy is unknown. Our primary aim was to determine whether the robotic approach to gastrectomy reduces postoperative opioid use compared with the open approach. METHODS: Patients who underwent gastrectomy (November 2018 to September 2021) were identified retrospectively. Clinical characteristics, short-term surgical outcomes, oral morphine equivalent (OME) use, and pain scores were collected. Both groups were managed through an enhanced recovery program in the perioperative period. RESULTS: Of 81 patients, 50 underwent open and 31 underwent robotic gastrectomy. Compared with open gastrectomy patients, robotic gastrectomy patients had longer surgery time (360 vs. 288 min), less blood loss (50 vs. 138 mL), and shorter hospital stay (4 vs. 6 days) (all medians, P < 0.001). Robotic gastrectomy patients used lower OMEs on postoperative days 0-4 (all P < 0.05) and in total for days 0-4 (total mean dose 65.0 vs. 169.5 mg; P < 0.001) than did open gastrectomy patients. The robotic gastrectomy patients were prescribed a lower mean OME dose than the open gastrectomy patients (19.0 vs. 29.0 mg, respectively; P = 0.001). Multivariable analysis showed that robotic approach was associated with lower opioid use (odds ratio 3.70; 95% CI 1.01-14.3; P = 0.049). CONCLUSIONS: Compared with open gastrectomy, robotic gastrectomy reduces opioid use in the early postoperative period and is associated with fewer OME discharge prescriptions and shorter hospital stay.

What is "Value"? Results of a Survey of Cancer Patients and Providers.

BACKGROUND: We measured the importance patients with gastrointestinal cancer and health care providers place on treatment outcomes, quality of life, and costs. METHODS: This cross-sectional survey study was conducted between June 1, 2020 and November 30, 2020. We identified surviving patients who had been treated or were anticipating treatment for pancreatic or gastric cancer at our single institution from January 1, 2000 through January 31, 2020. Surveys assessed the importance patients and providers placed on outcomes, well-being, costs, and experiences. Surveys measured how these values had changed over time. We compared the importance patients and providers place on each of the attributes of value. RESULTS: A total of 383 patients and 164 providers responded. Providers felt experience, emotional well-being, and costs were more important than patients themselves did (all p < 0.05). Patients more commonly reported that survival had become more important to them over time, while providers believed that emotional well-being, experience, and costs had become more important to patients (all p < 0.05). Postoperative patients ranked functional well-being as more important than preoperative patients did (p = 0.031). Patients of lower income and education levels more reported concerns of costs over the course of their care (both p < 0.05). Younger age was associated with concern for direct (r = -0.167, p = 0.004) and indirect costs (r = -0.318, p < 0.001). CONCLUSIONS: Although there are consistencies amongst the views of cancer patients and providers, there remain discordances in the perception of value. Patients' values differed across their treatment and survivorship course. These data demonstrate the importance of accounting for multistakeholder perspectives in assessments of value in health care.

Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients.

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

Patient-reported outcomes: Is this the missing link in patient-centered perioperative care?

Patient-reported outcomes (PROs) have been increasingly recognized as valuable information for delivery of optimal perioperative care to high-risk surgical patients in recent years. However, progress from clinical research on PROs has not been widely adopted in routine patient care. This review discusses the current concepts and practice status regarding PROs and addresses the missing links from research to practice adoption to further improve patient's experiences and clinical outcomes in perioperative care. Insufficient empirical research on appropriate PROs and its methodologies, insufficient implementation research to solve the practical issues, and insufficient data collection methods and experiences on ePROs are also discussed. Future research agenda should focus on evidence-supported, PRO-based symptom monitoring systems for early diagnosis and management of impending compromised clinical outcomes.

Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC).

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer.

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer. METHODS: We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications. RESULTS: One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0]; p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar. CONCLUSIONS: Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.

Surgical Outcomes in Cancer Patients Undergoing Elective Surgery After Recovering from Mild-to-Moderate SARS-CoV-2 Infection.

BACKGROUND: An increasing number of patients with cancer diagnoses and prior SARS-CoV-2 infection will require surgical treatment. The objective of this study was to determine whether a history of SARS-CoV-2 infection increases the risk of adverse postoperative events following surgery in patients with cancer. METHODS: This was a propensity-matched cohort study from April 6, 2020 to October 31, 2020 at the UT MD Anderson Cancer Center. Cancer patients were identified who underwent elective surgery after recovering from SARS-CoV-2 infection and matched to controls based on patient, disease, and surgical factors. Primary study outcome was a composite of the following adverse postoperative events that occurred within 30 days of surgery: death, unplanned readmission, pneumonia, cardiac injury, or thromboembolic event. RESULTS: A total of 5682 patients were included for study, and 114 (2.0%) had a prior SARS-CoV-2 infection. The average time from infection to surgery was 52 (range 20-202) days. Compared with matched controls, there was no difference in the rate of adverse postoperative outcome (14.3% vs. 13.4%, p = 1.0). Patients with a SARS-CoV-2-related inpatient admission before surgery had increased odds of postoperative complication (adjusted odds ratio [aOR] 7.4 [1.6-34.3], p = 0.01). CONCLUSIONS: A minimal wait time of 20 days after recovering from minimally symptomatic SARS-CoV-2 infection appears to be safe for cancer patients undergoing low-risk elective surgery. Patients with SARS-CoV-2 infections requiring inpatient treatment were at increased risk for adverse events after surgery. Additional wait time may be required in those with more severe infections.

Development of a patient-reported outcome tool for assessing symptom burden during perioperative care in liver surgery: The MDASI-PeriOp-Hep.

PURPOSE: Based on the MD Anderson Symptom Inventory (MDASI), we developed a Patient-reported outcomes tool for hepatectomy perioperative care (MDASI-PeriOp-Hep). METHODS: To establish the content validity, we generated PeriOp-Hep-specific candidate items from qualitative interviews of patients (n = 30), and removed items that lacked clinical relevance on the basis of input from panels of patients, caregivers, and clinicians. The psychometric properties of the MDASI-PeriOp-Hep were validated (n = 150). The cognitive debriefing and clinical interpretability were assessed to confirm the ease of comprehension, relevance, and acceptability of the tool. RESULTS: Five symptoms specific to hepatectomy (abdominal bloating, tightness, or fullness; abdominal cramping; muscle weakness, instability, or vertigo; constipation; and incisional tightness) were identified as module items to form the MDASI-PeriOp-Hep. The Cronbach αs for symptoms and for interference were 0.898 and 0.861, respectively. The test-retest reliability was 0.887 for all 18 symptom severity items. Compared to other commonly used tools, correlation of MDASI-PeriOp-Hep scores to performance status (all, P < 0.001) and to the phase of perioperative care confirmed known-group validity. Convergent validity was excellent against other standard Patient-reported outcomes tools. Cognitive debriefing demonstrated that the MDASI-PeriOp-Hep was an easy to use and understandable tool. CONCLUSIONS: For integrating patient-reported outcomes in perioperative patient care, a procedure-specific tool is desirable. The MDASI-PeriOp-Hep is a valid, reliable, concise tool for measuring symptom severity and functional interference in patients undergoing liver surgery.

Scaling an Enhanced Recovery Program to an Institution-Wide Initiative: It Takes a Village.

BACKGROUND AND OBJECTIVE: With the inclusion of Enhanced Recovery Programs (ERPs) into routine clinical practice, scaling programs across an institution is important to drive sustainable change in a patient-centric care delivery paradigm. A review of ERP implementation within a large institution was performed to understand key components that hinder or facilitate success of scaling an ERP. METHODS: From January 2018 to March 2018, a needs assessment was completed to review implementation of enhanced recovery across the institution. Implementation progress was categorized into one of 5 phases including Define, Implement, Measure, Analyze, and Optimize. RESULTS: Only 25% of service line ERPs reached the optimization phase within 5 years. One hundred percent of respondents reported more strengths (n = 41) and opportunities (n = 41) than weaknesses or threats (n = 25 and 14, respectively). Commonly identified strengths included established enhanced recovery pathways, functional team databases, and effective provider education. Weaknesses identified were inconsistencies in data quality/collection and a lack of key personnel participation including buy-in and time availability. Respondents perceived the need for data standardization to be an opportunity, while personnel factors were viewed as key threats. CONCLUSION: Identification of strengths, weaknesses, opportunities, and threats could prove beneficial in helping scale an ERP across an institution. Successful optimization and expansion of ERPs require robust data management for continuous quality improvement efforts among clinicians, administrators, executives, and patients.

Developing a Value Framework: Utilizing Administrative Data to Assess an Enhanced Care Initiative.

BACKGROUND: There remains no tool to quantify the total value of comparative processes in health care. Hospital administrative data sets are emerging as valuable sources to evaluate performance. Thus, we use a framework to simultaneously assess multiple domains of value associated with an enhanced recovery initiative using national administrative data. MATERIALS AND METHODS: Risk-stratified clinical pathways for patients undergoing pancreatic surgery were implemented in 2016 at our institution. We used a national administrative database to characterize changes in value associated with this initiative. Value metrics assessed included in-hospital mortality, complication rates, length of stay (LOS), 30-day readmission rates, and institutional costs. We compared our performance with other hospitals both before and after implementation of the pathways. Metrics were graphed on radar charts to assess overall value. RESULTS: 22,660 cases were assessed. Comparing 75 cases at our institution and 5520 cases at all other hospitals before pathway implementation, mean in-hospital LOS was 9.6 versus 10.8 d, in-hospital mortality was 0.0% versus 1.9%, mean costs were $23,585 versus $21,387, 30-day readmission rates were 1.3% versus 7.4%, and complication rates were 8.0% versus 11.2%, respectively. Comparing 334 cases at our institution and 16,731 cases at all other hospitals after pathway implementation, mean in-hospital LOS was 7.7 versus 10.3 d, in-hospital mortality was 0.3% versus 1.6%, mean costs were $19,428 versus $22,032, 30-day readmission rates were 6.6% versus 7.5%, and complication rates were 6.3% versus 10.3%, respectively. Notably, LOS and institutional costs were reduced at our institution after implementation of the enhanced clinical care pathways. Our costs were higher than comparators before implementation, but lower than comparators after implementation. CONCLUSIONS: Herein, we used an analytic framework and used national administrative data to assess the value of an enhanced care initiative as benchmarked with data from other hospitals. We thus illustrate how to identify and measure opportunities for targeted improvements in health care delivery. We also recognize the limitations of the use of administrative data in a comprehensive assessment of value in health care.

Assessment of physical function by subjective and objective methods in patients undergoing open gynecologic surgery.

OBJECTIVE: To evaluate the utility of patient-reported outcomes (PROs) to measure physical functioning in perioperative care for patients with gynecological (GYN) tumors. METHODS: 180 patients with GYN tumors undergoing open surgery participated in this longitudinal study. The physical functioning was measured by a subjective PRO tool, the Interference subscales of the MD Anderson Symptom Inventory (MDASI-I); as well as by an objective tool, the Timed Up & Go test (TUGT), perioperatively. Longer time (>20 s) needed to complete the TUGT was defined as "Prolonged". Patients completed EuroQoL-5D as well. The association between the scores of MDASI-I items and TUGT was assessed via the Spearman correlation coefficient. The known-group validity was assessed using the t-test and Cohen's D effect size. RESULTS: Compliance rates at preoperative, discharge and postoperative time points of MDASI-I were 98%, 95%, 96%; while TUGT completion rates were 92%, 75%, and 80%, respectively. Patients who had refused TUGT at discharge reported a significantly worse "MDASI-general activity" score compared to patients who completed TUGT (mean score of 7.00 vs. 5.38, P = 0.020). Patient-reported "Walking" on MDASI-I significantly differentiated patients with prolonged vs. those with frail/normal TUGT at discharge (mean score of 4.89 vs. 2.79, Cohen's d effect size = 0.82, P < 0.001). MDASI-I demonstrated excellent known-group validity per performance status and for the EuroQoL-5D subscales. CONCLUSION: Patient-reported physical functioning impairment after GYN surgery correspond with observed worse scores of the objective functioning measure test (TUGT). MDASI-I assessment represents a feasible and valid tool to evaluate functional status and warrants further implementation in the perioperative setting.