Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study.

INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.

Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial.

BACKGROUND: We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program. METHODS: We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated. RESULTS: Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048). CONCLUSIONS: Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2).

Importance: The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery. Objective: To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Design, Setting, and Participants: This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019. Exposures: Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not. Main Outcomes and Measures: The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality. Results: During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001). Conclusions and Relevance: An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Type of axial analgesia does not influence time to vaginal delivery in a Proportional Hazards Model.

OBJECTIVE: To create a Proportional Hazards Model of prospective factors associated with time-to-vaginal-delivery (TTVD). METHODS: We analyzed a group of 144 women undergoing childbirth who received one out of two possible axial analgesia techniques, to find-out factors associated with TTVD. The patients were randomly assigned to receive either a levobupivacaine labor epidural (bolus concentration 0.25 % or less; infusion concentration 0.125 % or less) or a combined spinal-epidural procedure (morphine 0.20 mg, fentanyl 25 µg and hyperbaric bupivacaine 2.5 mg as spinal components) for labor analgesia. The factors initially chosen were: mother age, height and weight, parity, gestational age, newborn weight, type of labor, analgesic procedure, levobupivacaine and fentanyl doses, Bromage scale, pain Numeric Rating Scale, and a satisfaction interview. Cesarean section was the censored variable in our model. A systematic multivariate Cox regression was performed. RESULTS: Our Final Model stated that nulliparous women had 2.5 times more chances of having longer TTVD than primiparous (p < 0.001, CI 1.76-3.8), and 3.4 times more (p = 0.015, CI 1.27-9.25) than multiparous. Women with oxytocin-augmented labor had 2.05 times more chances (p = 0.001, CI 1.31-3.22) of having longer TTVD than patients without oxytocin. An induced partum had 3.8 times more chances (p < 0.001, CI 2.09-6.8) of having longer TTVD compared to a spontaneous partum. CONCLUSION: Parity, labor augmentation, induction of labor and fetal weight determine TTVD; axial analgesia-related factors do not contribute to the model.

Effect of combined spinal-epidural analgesia versus epidural analgesia on labor and delivery duration.

OBJECTIVE: To determine whether combined spinal-epidural analgesia (CSEA) can decrease the known epidural effect of lengthening delivery. METHODS: Between April and May 2010, 144 women undergoing childbirth in hospital with epidural pain relief were randomized to receive either low-dose epidural analgesia (LEA) or CSEA. The spinal component included 2.5mg of bupivacaine, 25 µg of fentanyl, and 200 µg of morphine. The epidural component of the CSEA procedure was started once pain returned. The primary outcome was total labor duration measured from the time of initiation of labor analgesia to delivery. RESULTS: The difference in duration between LEA (n=72) and CSEA (n=72) was 5 minutes for labor (P=0.82), 2 minutes for delivery (P=0.60), and 7 minutes for total labor duration (P=0.75). The combined group used less levobupivacaine (P<0.001) and had lower sensory blockade at the dermatomal level (P=0.037). Women in the CSEA group had a higher incidence of pruritus (P=0.002) and lightheadedness (P=0.02) during labor; and a higher incidence of pruritus (P=0.002), nausea-vomiting (P=0.026), and drowsiness (P=0.003) in the postpartum period. CONCLUSION: As compared with LEA, CSEA did not shorten the duration of labor length; however, it did reduce levobupivacaine consumption and motor weakness.