A Pilot Study of a Screening Program for Human Papillomavirus-Related Squamous Intraepithelial Lesion and Malignancy in Gynecologic Oncology Patients.

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.

A Multidimensional Bioinformatic Platform for the Study of Human Response to Surgery.

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.

Combined Primary Resection with Hepatic Artery Infusion Pump Implantation Is Safe for Unresectable Colorectal Liver Metastases.

BACKGROUND: Colorectal liver metastases (CRLM) are the most common cause of disease-specific mortality in patients with colorectal cancer. Hepatic artery infusion (HAI) combined with systemic chemotherapy improves survival for these patients. The safety of colorectal resection at the time of HAI pump placement has not been well established. METHODS: Patients with CRLM who underwent combined HAI pump placement and colorectal (primary) resection or HAI pump placement alone were evaluated for perioperative outcomes, pump-specific complications, infectious complications, and time to treatment initiation. These outcomes were compared using comparative statistics. RESULTS: Patients who underwent combined HAI pump placement and primary resection (n = 19) vs HAI pump placement alone (n = 13) had similar demographics and rates of combined hepatectomy. Combined HAI pump placement and primary resection group had similar operative time and blood loss (both p = NS), but longer length of stay (6 vs 4 days, p = 0.02) compared to pump placement alone. Overall postoperative complications (21% vs 8%) and pump-specific complications (16% vs 31%) were similar (both p = NS). Infection rates were not different between groups, nor was time to initiation of HAI therapy (19 vs 16 days p = NS), or systemic therapy (34 vs 35 days p = NS). CONCLUSION: Combining colorectal resection with HAI pump implantation is a safe surgical approach for management of unresectable CRLM. Postoperative complications, specifically infectious complications, were not increased, nor was there a delay to initiation of HAI or systemic chemotherapy. Investigation of long-term oncologic outcomes for HAI pump placement and primary tumor resection in patients with unresectable CRLM is ongoing.

Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways aim to standardize and integrate perioperative care, incorporating the best available evidence-based practice throughout the perioperative period targeted at attenuating the surgical stress response while optimizing physiologic function, with the goal of facilitating recovery. Radical cystectomy is associated with significant postoperative morbidity, but comprehensive ERAS pathways have not been well studied in this population. METHODS: This is a before and after cohort study of an ERAS pathway for radical cystectomy at a large academic medical center. Following introduction of the ERAS pathway and a wash in period, we prospectively collected data from the next 100 consecutive subjects undergoing radical cystectomy with the ERAS pathway. This cohort was compared to a retrospective cohort of 100 consecutive patients undergoing radical cystectomy with traditional care. The primary outcome was hospital length of stay. Secondary outcomes included perioperative management, time to recovery milestones, complications, and costs. RESULTS: Implementation of an ERAS pathway for radical cystectomy was associated with reduced hospital length of stay (median LOS 10 days (IQR = 8-18) vs 7 days (IQR = 6-11); p < 0.0001), reduced time to key recovery milestones, including days to first stool (5.83 vs 3.99; p < 0.001) and days to first solid food (9.68 vs 3.2; p < 0.001), reductions in some complications, and a 26.6% reduction in overall costs (p < 0.001). CONCLUSIONS: Our data support the use of an ERAS pathway for radical cystectomy and add to the increasing body of literature supporting enhanced recovery over a wide variety of procedures. TRIAL REGISTRATION: Not applicable.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients.

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.

Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery.

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.

American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives.

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.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy.

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.

Adherence to Enhanced Recovery Protocols in NSQIP and Association With Colectomy Outcomes.

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.

Effect of Diagnosis on Outcomes in the Setting of Enhanced Recovery Protocols.

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.

Correction to: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2-From PACU to the Transition Home.

[This corrects the article DOI: 10.1186/s13741-017-0063-6.].

Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative.

Importance: Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective: To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants: Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures: Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results: One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Conclusions and Relevance: Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway.

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.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Patient-Reported Outcomes in an Enhanced Recovery Pathway.

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.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery.

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.

Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program.

Importance: Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. Objective: To evaluate the association of the ERIN pilot with LOS after colectomy. Design, Setting, and Participants: Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. Interventions: Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. Main Outcomes and Measures: The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. Results: There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). Conclusions and Relevance: Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.

Enhanced recovery protocols for colorectal surgery and postoperative renal function: a retrospective review.

BACKGROUND: While enhanced recovery protocols (ERPs) reduce physiologic stress and improve outcomes in general, their effects on postoperative renal function have not been directly studied. METHODS: Patients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single institution. Multivariable regression models examined the association of ERP with postoperative creatinine changes and incidence of postoperative acute kidney dysfunction (based on the Risk, Injury, Failure, Loss, and End-stage renal disease criteria). RESULTS: Included were 1054 patients: 590 patients underwent surgery with ERP and 464 patients without ERP. Patient demographics were not significantly different. Higher rates of neoplastic and inflammatory bowel disease surgical indications were found in the ERP group (81 vs. 74%, p = 0.045). Patients in the ERP group had more comorbidities (ASA ≥ 3) (62 vs. 40%, p < 0.001). In unadjusted analysis, postoperative creatinine increase was slightly higher in the ERP group compared with control (median 0.1 vs. 0 mg/dL, p < 0.001), but levels of postoperative acute kidney injury were similar in both groups (p = 0.998). After adjustment with multivariable regression, postoperative changes in creatinine were similar in ERP vs. control (p = 0.25). CONCLUSIONS: ERP in colorectal surgery is not associated with a clinically significant increase in postoperative creatinine or incidence of postoperative kidney injury. Our results support the safety of ERPs in colorectal surgery and may promote expanding implementation of these protocols. TRIAL REGISTRATION: Not applicable, prospective data collection and retrospective chart review only.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2-From PACU to the Transition Home.

BACKGROUND: Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia", which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. METHODS: With input from a multidisciplinary, international group of experts and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. DISCUSSION: As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery within an ERP. The goal was twofold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus on care in the post-anesthesia care unit, general care ward, and transition to home after discharge. The preoperative and operative consensus statement for analgesia was covered in Part 1 of this paper. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of "optimal analgesia" as set forth in this document.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU.

BACKGROUND: Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia," which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. METHODS: With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. DISCUSSION: As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.

Structured reporting of CT enterography for inflammatory bowel disease: effect on key feature reporting, accuracy across training levels, and subjective assessment of disease by referring physicians.

PURPOSE: To compare the content and accuracy of structured reporting (SR) versus non-structured reporting (NSR) for computed tomographic enterography (CTE) of inflammatory bowel disease (IBD). MATERIALS AND METHODS: This IRB-approved, HIPAA-compliant, retrospective study included 30 adult subjects (15 male, 15 female; mean age 41.9 years) with IBD imaged with CTE. Nine radiologists (3 faculty, 3 abdominal imaging fellows, and 3 senior radiology residents) independently interpreted all examinations using both NSR and SR, separated by four weeks. Reports were assessed for documentation of 15 key reporting features and a subset of 5 features was assessed for accuracy. Thirty faculty reports (15 NSR [5 per reader] and 15 SR [5 per reader]) were randomly selected for review by three referring physicians, who independently rated quality metrics for each report. RESULTS: NSR documented the presence or absence of 8.2 ± 2.2 key features, while SR documented 14.6 ± 0.5 features (p < 0.001). SR resulted in increased documentation of 13 of 15 features including stricture (p < 0.001), fistula (p < 0.001), fluid collection (p = 0.003), and perianal disease (p < 0.001). Among a subset of five features, accuracy for diagnosing multifocal disease was minimally increased when using SR (76% NSR vs. 83% SR; p = 0.01), but accuracy for other features was not affected by report type. Referring physicians significantly preferred SR based on ease of information extraction (p < 0.01). CONCLUSION: Structured reporting of CTE for IBD improved documentation of key reporting features for trainees and faculty, though there was minimal impact on accuracy. Referring physicians subjectively preferred the structured reports.