Evaluation of an Innovative Care Pathway in the Diagnostic and Therapeutic Management of Hepatobiliary and Pancreatic Pathologies: "One-Day Diagnosis".

"One-Day Diagnosis" (1DD) for hepatobiliary and pancreatic (HBP) diseases is an innovative care pathway that combines, on the same day, surgical consultation, medical imaging, anesthesia, diagnosis announcement, and therapeutic support consultations. The objective was to evaluate the length of the 1DD care pathway compared to a conventional one. The prospective "1DD care pathway" arm included 330 consecutive patients (January 2017−April 2019) vs. 152 (November 2014−November 2015) in the retrospective "conventional" one. In the 1DD group, diagnosis was made on the same day in 83% of consultations vs. 68.4% (p = 0.0005). Although there was no difference in overall time to diagnosis, diagnostic and therapeutic management was faster in the 1DD group (1 day vs. 15 days, p < 0.0004). In addition, 77% of patients who benefited from 1DD were very satisfied with their treatment overall. The mean cost of the 1DD consultation was EUR 176.8 +/− 149 (range: 50−546). The median cost of the overall program was similar (EUR 584 vs. EUR 563, p = 0.67). As an organizational innovation, the 1DD for HBP pathologies is a promising care pathway that optimizes diagnostic and therapeutic management, without creating medical overconsumption or additional costs. Given patient satisfaction, this model should be generalized to optimize cancer care by adapting it to the constraints of different healthcare structures.

Persistent neuropathic pain after inguinal herniorrhaphy depending on the procedure (open mesh v. laparoscopy): a propensity-matched analysis.

BACKGROUND: A greater incidence of persistent pain after inguinal herniorrhaphy is suspected with the open mesh procedure than with laparoscopy (transabdominal preperitoneal), but the involvement of neuropathy needs to be clarified. METHODS: We examined the cumulative incidence of neuropathic persistent pain, defined as self-report of pain at the surgical site with neuropathic aspects, within 6 months after surgery in 2 prospective subcohorts of a multicentre study. We compared open mesh with laparoscopy using different analysis, including a propensity-matched analysis with the propensity score built from a multivariable analysis using a generalized linear model. RESULTS: Considering the full patient sample (242 open mesh v. 126 laparoscopy), the raw odds ratio for neuropathic persistent pain after inguinal herniorrhaphy was 4.3. It reached 6.8 with the propensity-matched analysis conducted on pooled subgroups of 194 patients undergoing open mesh and 125 undergoing laparoscopy (95% confidence interval 1.5-30.4, p = 0.012). A risk factor analysis of these pooled subgroups revealed that history of peripheral neuropathy was an independent risk factor for persistent neuropathic pain, while older age was protective. CONCLUSION: We found a greater risk of persistent pain with open mesh than with laparoscopy that may be explained by direct or indirect lesion of nerve terminations. Strategies to identify and preserve nerve terminations with the open mesh procedure are needed.

CONTEXTE: On soupçonne que l'incidence de la douleur persistante à la suite d'une hernioplastie inguinale est plus élevée avec la mise en place d'un filet par voie ouverte qu'avec la laparoscopie (transabdominale prépéritonéale), mais encore faut-il clarifier le rôle de la neuropathie. MÉTHODES: Nous avons mesuré l'incidence cumulative de la douleur neuropathique persistante, décrite comme une douleur au site opératoire accompagnée d'éléments neuropathiques déclarés par le patient dans les 6 mois suivant la chirurgie, auprès de 2 sous-cohortes prospectives d'une étude multicentrique. Nous avons comparé la mise en place d'un filet par voie ouverte et la laparoscopie à l'aide de différentes analyses, dont une analyse avec appariement des scores de propension, les scores de propension découlant d'une analyse multivariée générée à partir d'un modèle linéaire généralisé. RÉSULTANTS: En tenant compte de tout l'échantillon de patients (242 soumis à la mise en place d'un filet par voie ouverte c. 126 soumis à la laparoscopie), le rapport des cotes brut pour la douleur neuropathique persistante après l'hernioplastie inguinale était de 4,3. Il a atteint 6,8 à l'analyse par appariement des scores de propension réalisée auprès de sous-groupes réunis de 194 patients soumis à la technique ouverte avec treillis et 125 soumis à la laparoscopie (intervalle de confiance à 95 % 1,5­30,4, p = 0,012). Une analyse des facteurs de risque pour ces sous-groupes réunis a révélé que des antécédents de neuropathie périphérique constituaient un facteur de risque indépendant à l'égard de la douleur neuropathique persistante, tandis que l'avancée en âge a conféré un effet protecteur. CONCLUSION: Nous avons observé un risque plus élevé de douleur persistante associée à la mise en place d'un filet par voie ouverte qu'avec la laparoscopie, ce qui pourrait s'expliquer par des lésions directes ou indirectes aux terminaisons nerveuses. Des stratégies s'imposent pour identifier et préserver les terminaisons nerveuses lors de la mise en place d'un filet par voie ouverte.

Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study.

BACKGROUND: Blockade of parietal nociceptive afferents by the use of continuous wound infiltration with local anesthetics may be beneficial in a multimodal approach to postoperative pain management after major surgery. The role of continuous preperitoneal infusion of ropivacaine for pain relief and postoperative recovery after open colorectal resections was evaluated in a randomized, double-blinded, placebo-controlled trial. METHODS: After obtaining written informed consents, a multiholed wound catheter was placed by the surgeon in the preperitoneal space at the end of surgery in patients scheduled to undergo elective open colorectal resection by midline incision. They were thereafter randomly assigned to receive through the catheter either 0.2% ropivacaine (10-ml bolus followed by an infusion of 10 ml/h during 48 h) or the same protocol with 0.9% NaCl. In addition, all patients received patient-controlled intravenous morphine analgesia. RESULTS: Twenty-one patients were evaluated in each group. Compared with preperitoneal saline, ropivacaine infusion reduced morphine consumption during the first 72 h and improved pain relief at rest during 12 h and while coughing during 48 h. Sleep quality was also better during the first two postoperative nights. Time to recovery of bowel function (74 +/- 19 vs. 105 +/- 54 h; P = 0.02) and duration of hospital stay (115 +/- 25 vs. 147 +/- 53 h; P = 0.02) were significantly reduced in the ropivacaine group. Ropivacaine plasma concentrations remained below the level of toxicity. No side effects were observed. CONCLUSIONS: Continuous preperitoneal administration of 0.2% ropivacaine at 10 ml/h during 48 h after open colorectal resection reduced morphine consumption, improved pain relief, and accelerated postoperative recovery.