Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.

BACKGROUND: ERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development. METHODS: The ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence. RESULTS: Clear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus-based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up-to-date evidence is used consistently to support surgical patients. CONCLUSION: There is a need for a standardized, evidence-informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines.

ANTECEDENTES: Las guías de la sociedad ERAS® (Enhanced Recovery After Surgery) son herramientas holísticas y multidisciplinares diseñadas para mejorar los resultados después de la cirugía. Los programas ERAS (guías de recuperación intensificada) se desarrollaron inicialmente para la cirugía colorrectal y se han implementado con éxito en muchos otros ámbitos, lo que resulta en mejores resultados para los pacientes. A medida que los programas ERAS se adoptan cada vez más en todo el mundo y se generan nuevas guías para nuevas poblaciones, es necesario definir una guía clínica de la sociedad ERAS® y la metodología a seguir para su desarrollo. MÉTODOS: La sociedad ERAS® recomienda que el enfoque para desarrollar las nuevas guías se base en el establecimiento de grupos multidisciplinares responsables de la definición de los temas, planteamiento de la revisión de la literatura y valoración de la calidad de la evidencia. RESULTADOS: Las definiciones precisas de los elementos de una guía ERAS implican enfoques multimodales y multidisciplinares que tengan en cuenta los múltiples resultados que afectan a los pacientes. La metodología recomendada para el desarrollo de guías debe seguir un enfoque riguroso con identificación sistemática y evaluación de evidencia, y el desarrollo de recomendaciones basadas en el consenso. Posteriormente, las guías deben evaluarse y revisarse regularmente para garantizar que la evidencia mejor y más actualizada se aplique al manejo de los pacientes quirúrgicos. CONCLUSIÓN: Es necesario un enfoque estandarizado, basado en la evidencia, tanto para el desarrollo de nuevas guías de la sociedad ERAS® como para la adaptación y revisión de las guías ya existentes.

Patch repair is an independent predictor of morbidity and mortality in congenital diaphragmatic hernia.

BACKGROUND: Infants with congenital diaphragmatic hernia (CDH) have variable outcomes. There is a considerable potential benefit in being able to predict perinatally, which infants have severe hypoplasia and are thus more likely to die or survive with significant morbidity. We examine the relationship between a need for patch repair of CDH (PR) and outcome, using a national database. METHODS: Baseline characteristics of patients undergoing PR or non-patch repair (NPR) were compared. Multivariate analysis was performed to determine the association of PR with mortality and morbidity independent of other known predictors. RESULTS: Baseline characteristics of PR and NPR infants were similar although those infants with PR had higher SNAP-II scores. PR was an independent predictor of mortality with an odds ratio of 17.1 (95%CI 2.0-149.2) and was independently associated with secondary outcome measures of morbidity, including the need for oxygen at discharge and the duration of ventilation. CONCLUSIONS: Infants requiring PR have significantly higher mortality and suffer greater morbidity than those undergoing NPR. This association is independent of other known predictors of mortality. Identifying prenatal features associated with this high risk group would be of great clinical value.

Impact of target blood gases on outcome in congenital diaphragmatic hernia (CDH).

INTRODUCTION: Neonatal intensive care unit (NICU) stabilization strategies which normalize physiology according to predetermined blood gas targets may contribute to observed improved survival rates of patients with CDH. The purpose of our study was to compare risk-adjusted outcomes of CDH patients managed with or without blood gas targets established at NICU admission. METHODS: Cases were collected from a national CDH network between May 2005 and November 2007. On NICU admission, the responsible neonatologist was asked to establish target ranges for pH, pCO (2), pO (2), and pre/post-ductal O (2) saturation. The outcomes analyzed were mortality, need for ECMO, days of mechanical ventilation/supplemental oxygen, and length of stay. RESULTS: Of 147 CDH infants, 63 had admission blood gas targets. Severity of illness and gestational age in both groups were comparable (SNAP-II score). Infants with blood gas targets had a significantly lower mortality than those without (Hazard ratio 0.27, p=0.006). CONCLUSIONS: Blood gas targets for the management of infants with CDH are associated with improved survival. Although the willingness to create and use stabilization targets to guide early NICU care may be a surrogate for other factors (experience, staffing, lack of interest), it is clearly associated with improved survival in CDH.

Improved outcomes in paediatric intestinal failure with aggressive prevention of liver disease.

BACKGROUND/PURPOSE: A protocol-driven care algorithm for the care of intestinal failure (IF) centred on therapies to prevent Parenteral Nutrition Associated Cholestasis (PNAC) was instituted in 2006. We report our results from 2006-2009, and compare them to the outcomes of our previous cohort of patients (1998-2006). METHODS: With regional ethics board approval, we have been prospectively gathering data on patient with IF cared for by our regional surgical unit. IF was defined as a residual bowel length of <40 cm or a requirement for PN for greater than 60 days. With the development of a multidisciplinary care team, a protocol-driven strategy to prevent PNAC was instituted in 2006, with aggressive introduction of enteral feeds, use of prophylactic antibiotics to prevent bacterial overgrowth, lipid reduction and use of a fish oil-derived lipid preparation for cholestasis and Serial Transverse Enteroplasty (STEP) if bowel dilation occurred. RESULTS: In the era from 1998-2006, 33 patients were identified, with a 72% survival; the direct bilirubin averaged 112+/-34 microM/L after 3 months of PN. 8/33 (27%) of patients received prophylactic antibiotics, and none received fish oil-based lipids. The most common causes of IF were gastroschisis (30%) and atresia (21%); 31 of 33 patients were infants. Average time to intestinal rehabilitation/death was 4.5+/-3 months. All deaths were related to sepsis or PN/liver failure. In the era from 2006-2009, 22 patients have been followed, with 100% survival*. Average bilirubin after 3 months of PN was 8+/-2.2 microM/L*, 20/22 (90%)* received prophylactic antibiotics, and 6/22(27%)* received fish oil-based lipid PN. The common causes of IF were gastroschisis 15/22 (68%) and atresia (27%). 18/22 are weaned from PN, and the average time to intestinal rehabilitation was 2.7+/-1.3 months, 4 patients underwent STEP procedures. (*p<0.05 by Fischer's exact or Student's t-test, data mean+/-SD). CONCLUSIONS: The institution of an aggressive protocol of advancing enteric feeds, oral antibiotic prophylaxis for bacterial overgrowth, fish oil-based lipid use, and the STEP procedure for dilated bowel has resulted in an apparent increase in survival and a remarkable improvement in liver function in a paediatric IF population. Further studies to define the relative importance of these therapies are recommended.

Fetal therapy with rhIGF-1 in a rabbit model of intrauterine growth retardation.

BACKGROUND: Intrauterine growth retardation (IUGR) may, in part, be due to a deficiency of insulin-like growth factor-1 (IGF-1). The objectives of this study were to determine the relationship between fetal serum IGF-1 levels and fetal and placental size in a rabbit model of IUGR and to compare two techniques of selective, exogenous IGF-1 administration (transamniotic and branch uterine arterial catheter infusion) to growth-retarded fetuses in utero. MATERIALS AND METHODS: Pregnant rabbits (n = 6) had their fetuses harvested near term (31 days) for fetal and placental weighing and serum collection. Growth-retarded fetuses were selectively infused for 7 days with recombinant human IGF-1 (rhIGF-1; 1,440 ng/day) either through a transamniotic catheter (n = 8) or via an adjacent uterine arterial branch catheter (n = 6). Opposite horn runts were sham catheterized, but not infused. At term, the fetal runt pairs and their placentas were harvested and weighed, and their serum was collected. The correlation between fetal and placental weight and endogenous serum IGF-1 was calculated (Pearson coefficient, r), while paired t-tests were used to compare the means between the IGF-1-infused and control groups. RESULTS: There was a significant correlation between fetal (r = 0.4230; P = 0.022) and placental weight (r = 0.4166; P = 0.025) and endogenous serum levels of IGF-1. Transamniotic infusion of rhIGF-1 was associated with an increase in serum IGF-1 level (254 +/- 79 vs 351 +/- 101 ng/ml, P = 0.04) and placental weight (5.4 +/- 2.3 vs 7.1 +/- 3.2 g, P = 0.005), and with a trend toward increased fetal weight between matched fetal runt pairs. Fetal mortality in the uterine arterial catheterized group was 76%, and there was no significant difference in fetal or placental weight or IGF-1 levels between infused and noninfused survivors. CONCLUSIONS: Endogenous fetal serum levels correlate with fetal and placental size in the rabbit IUGR model. Transamniotic administration of rhIGF-1 significantly increases serum IGF-1 levels and placental weight of fetal runts, while uterine vessel catheterization results in prohibitive fetal mortality and does not increase fetal or placental growth or IGF-1 levels.

Minimally invasive laparotomy for treatment of neonatal ovarian cysts.

BACKGROUND/PURPOSE: The optimal management of neonatal simple ovarian cysts greater than 4 cm is not known. The authors describe a safe, simple, definitive surgical technique. METHODS: We report 5 cases of simple ovarian cysts greater than 4 cm treated at the authors' institution between 1998 and 1999. All initial ultrasound findings were consistent with simple ovarian cysts greater than 4 cm. All patients underwent minimally invasive laparotomy. Length of operation ranged between 28 and 49 minutes. There were no intraoperative nor postoperative complications. The operation did not delay discharge. All patients were taking enteral nutrition and required no analgesia by postoperative day 1. No patient had recurrence of the ovarian cysts when screened by ultrasound scan at 4 months of age. CONCLUSION: Minimally invasive laparotomy provides a safe, definitive treatment for neonatal ovarian cysts greater than 4 cm. J Pediatr Surg 36:868-869.

Surgical treatment of aortic arch hypoplasia in infants and children with biventricular hearts.

BACKGROUND: Results of aortic arch reconstruction in the setting of biventricular physiology are well documented in the adult population, however, in children, surgical outcome of this subgroup of patients is less clear. METHODS: We studied the clinical outcomes of 37 children aged 8 days to 15 years (median 26 months), who underwent aortic arch reconstruction for arch hypoplasia from 1982 to 1997. The children were divided into three groups: Group 1 (20 patients) had isolated aortic arch lesions, Group 2 (13 patients) had associated intra-cardiac pathology yet conserving a biventricular physiology, Group 3 (4 patients) had Williams Syndrome. Previous interventions for coarctation had been performed in 30 patients (81%). Arch repair consisted of a patch aortoplasty in the majority of patients (35 of 37 children). RESULTS: Operative mortality occurred in 5 children, 4 in Group 2 (31%), 1 in Group 3 (25%) and none in Group 1. Permanent neurological complications occurred in 2 children (5 %). During the follow-up, which ranged from 1 month to 8 years, balloon angioplasty for arch obstruction was required in 1 child. There was one late death, associated with a subsequent intra-cardiac repair. CONCLUSIONS: Aortic arch surgery in children with isolated arch hypoplasia, is associated with excellent early and late survival in addition to a low reintervention rate. Alternative perfusion and operative strategies must be implemented in infants with associated intra-cardiac anomalies to improve results.

Compliance with guidelines for choice of radiographic projections: a multicentre study.

A study of compliance with guidelines for choice of radiographic projections was carried out in each of six centres. The study concerned 5851 examinations undertaken by 116 radiographers under the supervision of 29 consultant radiologists. The results showed good compliance between centres for examination of the chest (range 81-93%), abdomen (range 73-100%), thoracic spine (range 82-96%), pelvis/hip (range 78-99%) but not for examination of cervical spine (range 0-85%), paranasal sinus (range 0-100%) and lumbar spine (range 52-84%). The reasons given for these wide variations are discussed and estimates are given for the potential reductions in exposure to the UK population consequent upon national implementation of guidelines such as these.