Impact of standardized clinical pathways on esophagectomy: a systematic review and meta-analysis

2021 ◽  
Author(s):  
Francesco Puccetti ◽  
Bas P L Wijnhoven ◽  
MadhanKumar Kuppusamy ◽  
Michal Hubka ◽  
Donald E Low
Keyword(s):  
Enhanced Recovery ◽  
Clinical Pathways ◽  
Meta Analysis ◽  
Postoperative Mortality ◽  
Quality Criteria ◽  
High Volume ◽  
Pulmonary Complications ◽  
Readmission Rates ◽  
Variable Approach ◽  
Cochrane Database

Summary Esophageal surgery is historically associated with adverse postoperative outcomes. Selected high-volume centers have previously reported the effect on clinical outcomes following the adoption of a standardized clinical pathway (SCP). This meta-analysis aims to evaluate the current literature to document the effect of SCP and enhanced recovery after surgery (ERAS) on esophagectomy outcomes. A literature search was conducted through the main search engines (PubMed, Embase, Medline, and Cochrane database) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All eligible comparative studies (randomized control trial, prospective, retrospective, and combined) were identified and assessed based on Methodological Index for Non-Randomized Studies and Jadad quality criteria. Data concerning overall morbidity, early mortality, and length of stay (LOS) were primarily collected and compared. Secondary outcomes included anastomotic leaks, pulmonary complications, and readmission rate. Twenty-six articles (including five randomized controlled trials and six prospective trials) were included in the analysis. Overall study quality was moderate and the included studies utilized a variable approach to SCP. No statistically significant differences were found between groups in terms of overall morbidity, postoperative mortality, anastomotic leak, and readmission rates. Significant improvements included pulmonary complications (odds ratios [OR] 0.66, 95% confidence interval [CI] 0.49–0.94) and hospital LOS (OR −3.68, 95% CI −4.49 to −2.87). Previous reports of SCP within esophagectomy programs have demonstrated clinical improvements in postoperative pulmonary complications and LOS. Given the high heterogeneity historically demonstrated within SCPs, further improvement in outcomes should be expected following the adoption of standardized ERAS guidelines.

The effects of centralizing cancer surgery on postoperative mortality: A systematic review and meta-analysis

2021 ◽  
pp. 135581962110089
Author(s):  
Roberto Grilli ◽  
Federica Violi ◽  
Maria Chiara Bassi ◽  
Massimiliano Marino
Keyword(s):  
Evaluation Studies ◽  
Meta Analysis ◽  
Postoperative Mortality ◽  
Interrupted Time Series ◽  
High Volume ◽  
Cancer Surgery ◽  
Interrupted Time Series Analysis ◽  
Meta Regression ◽  
Meta Regression Analysis ◽  
After Cancer

Objectives To review the evidence of the effects of centralization of cancer surgery on postoperative mortality. Methods We searched Medline, Embase, Cinahl, Cochrane and Scopus (up to November 2019) for studies that (i) assessed the effects of centralization of cancer surgery policies on in-hospital or 30-day mortality, or (ii) described changes in both postoperative mortality for a surgical intervention and degree of centralization using reduction in the number of hospitals or increases in the proportion of patients undergoing cancer surgery at high volume hospitals as proxy. PRISMA guidelines were followed. We estimated pooled odds ratios (OR) and conducted meta-regression to assess the relationship between degree of centralization and mortality. Results A total of 41 studies met our inclusion criteria of which 15 evaluated the effect of centralization policies on postoperative mortality after cancer surgery and 26 described concurrent changes in the degree of centralization and postoperative mortality. Policy evaluation studies mainly used before-after designs (n = 13) or interrupted time series analysis (n = 2), mainly focusing on pancreatic, oesophageal and gastric cancer. All but one showed some degree of reduction in postoperative mortality, with statistically significant effects demonstrated by six studies. The pooled odds ratio for centralization policy effect was 0.68 (95% Confidence interval: 0.54–0.85; I2 = 80%). Meta-regression analysis of the 26 descriptive studies found that an increase of the proportion of patients treated at high volume hospitals was associated with greater reduction in postoperative mortality. Conclusions Centralization of cancer surgery is associated with reduced postoperative mortality. However, existing evidence tends to be of low quality and estimates of the effect size are likely inflated. There is a need for prospective studies using more robust approaches, and for centralization efforts to be accompanied by well-designed evaluations of their effectiveness.

scholarly journals Perioperative complications of esophagectomy - prevention, diagnosis and management

2017 ◽  
Vol 64 (1) ◽  
pp. 27-38
Author(s):  
Dejan Stojakov ◽  
Predrag Sabljak ◽  
Bratislav Spica ◽  
Dejan Velickovic ◽  
Vladimir Sljukic ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Perioperative Complications ◽  
Rapid Development ◽  
Postoperative Mortality ◽  
High Volume ◽  
Esophageal Resection ◽  
Vocal Cord Palsy ◽  
Pulmonary Complications ◽  
High Rate ◽  
Septic Complications

Esophageal resection with reconstruction is complex surgical procedure with high rate of postoperative morbidity, with decreasing mortality rate during last decades, particularly in high-volume hospitals. Numerous preoperative, intraoperative and postoperative factors have contribute to incidence and type of complications. Intraoperative haemorrhage and tracheobronchial lesions could be avoid by good surgical judgement and operative technique. Pulmonary complications are often, with multifactorial etiology, and they are the main cause of postoperative mortality after esophagectomy. Dehiscence of esophageal anastomosis could be fatal, and only high index of suspicion and early diagnosis lead to successful treatment. In majority of such cases conservative measures are successful, however, conduit necrosis is indication for surgical reoperation. Vocal cord palsy due to intraoperative injury of recurrent laryngeal nerves is not rare and increases pulmonary complications rate. New onset of arrhythmia could be associate with other surgical complications. Postesophagectomy chylothorax is life-threatening complication due to rapid development of immunosuppression and septic complications, and early ligation of thoracic duct is often mandatory. Intrathoracic herniation of intrabdominal viscera is rare, and ischemic spinal cord lesions are very rare after esophagectomy. Majority of perioperative complications could be prevented or solved, decreasing mortality rate of esophagectomy.

Is goal-directed fluid therapy beneficial for gastrointestinal surgery within an enhanced recovery program? A systematic review and meta-analysis

2020 ◽  
Keyword(s):  
Fluid Therapy ◽  
Postoperative Ileus ◽  
Postoperative Morbidity ◽  
Enhanced Recovery ◽  
Meta Analysis ◽  
Gastrointestinal Surgery ◽  
Postoperative Mortality ◽  
Current Evidence ◽  
Anastomotic Leaks ◽  
Goal Directed Fluid Therapy

Objectives: To systematically evaluate the clinical effect of intraoperative goal-directed fluid therapy (GDFT) in gastrointestinal surgery within an enhanced recovery after surgery (ERAS) program. Methods: EMBASE, MEDLINE, Cochrane Library, PubMed, OVID, CNKI and other databases were searched for randomized controlled trials (RCTs) from the inception dates to December 2018. These studies included patients undergoing elective gastrointestinal surgery comparing regular fluid therapy versus GDFT within ERAS. The meta-analysis was carried on with RevMan 5.3. Results: A total of 10 RCT studies were included with 1216 patients. Compared with the regular fluid therapy group, the GDFT group reduced the rate of readmission [odds ratio, OR = 1.67, 95% CI (1.05, 2.65), P = 0.03] in gastrointestinal surgery patients within ERAS. However, there was no significant decrease in length of hospital stay (LOHS) [mean difference, MD = -0.11, 95% CI (-1.22, 1.00), P = 0.85], postoperative morbidity [OR = 0.78, 95% CI (0.55, 1.11), P = 0.17], postoperative mortality [OR = 0.86, 95% CI (0.30, 2.49), P = 0.78], postoperative ileus [OR = 1.24, 95% CI (0.70, 2.19), P = 0.45], anastomotic leaks [OR= 0.66, 95% CI (0.29, 1.49), P = 0.31] and the first gastrointestinal motility time [MD = -0.37, 95% CI (-1.07, 0.33), P = 0.30]. Conclusions: The current evidence demonstrates that, in gastrointestinal surgery within ERAS, GDFT decreased the rate of readmission. However, there was no advantage over regular fluid therapy in the reduction of LOHS, postoperative morbidity, postoperative mortality, postoperative ileus and anastomotic leaks.

scholarly journals Enhanced Recovery after Renal Transplantation Decreases Recipients’ Urological Complications and Hospital Stay: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 10 (11) ◽  
pp. 2286
Author(s):  
Apostolos Prionas ◽  
Charles Craddock ◽  
Vassilios Papalois
Keyword(s):  
Renal Transplant ◽  
Perioperative Care ◽  
Enhanced Recovery ◽  
Meta Analysis ◽  
Renal Transplant Recipients ◽  
Transplant Recipients ◽  
Readmission Rates ◽  
Post Transplant ◽  
Urological Complications ◽  
One Year

The objective of this study was to compare enhanced recovery after surgery (ERAS) against traditional perioperative care for renal transplant recipients. Outcome measures included complications, length of stay (LOS), readmission rates, graft and patient survival up to one-year post-transplant. We initially screened Medline, Cochrane, Scopus, Embase and Web of Science databases. We identified 3029 records. From these, 114 full texts were scrutinized for inclusion. Finally, 10 studies were included in the meta-analysis corresponding to 2037 renal transplant recipients. ERAS resulted in lower incidence of urological complications (95CI: 0.276, 0.855) (I2 = 53.08%) compared to traditional perioperative practice. This referred to ureteric stenoses (95CI: 0.186–0.868) (I2 = 0%) and urinary tract infections (95CI: 0.230–0.978) (I2 = 71.55%). ERAS decreased recipients’ LOS (95CI: −2.876, −0.835) (I2 = 86.55%). Compared to standard practice, ERAS protocols did not increase unplanned readmissions (95CI:0.800, 1.680) (I2 = 0%). Up to one-year post-transplant, graft survival rates were similar across the ERAS and the control groups (95CI:0.420, 1.722) (I2 = 0%). There was also no difference in recipients’ one-year post-transplant survival (95CI:0.162, 3.586) (I2 = 0%). Our results suggest that ERAS protocols can be safely incorporated in the perioperative care of renal transplant recipients, decrease their urological complications and shorten their length of hospital stay without affecting unplanned readmission rates.

P21 FEASIBILITY OF ENHANCED RECOVERY PROTOCOL AFTER ESOPHAGEAL SURGERY IN ELDERLY PATIENTS

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
C A De Pasqual ◽  
J Weindelmayer ◽  
R La Mendola ◽  
L Alberti ◽  
C Ridolfi ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Enhanced Recovery ◽  
High Volume ◽  
Young Group ◽  
Pulmonary Complications ◽  
Esophageal Surgery ◽  
Morbidity Rate ◽  
Cardiac Complications ◽  
Soft Diet ◽  
Complications Rate

Abstract Background In dedicated centres ERAS (Enhanced Recovery After Surgery) programs have been successfully applied after esophageal surgery. However, some concerns have been raised about the feasibility of these protocols in elderly patients. Methods We retrospective reviewed 72 patients submitted to Ivor-Lewis esophagectomy in our Institution, during the period 2015-2017. We divided the patients into two groups: 47 patients (65,3%) were <70 years old (Young Group, YG) while 25 patients (34,7%) were ≥70 years old (Elderly Group, EG). We compared post-operative outcomes and adherence to ERAS steps of the two groups. Results The two groups were not different in terms of overall morbidity rate (53,2% in YG vs 60,0% in EG p= 0,6) and pulmonary complications rate (70,2% in YG vs 72,0% in EG, p= 1). EG showed a higher cardiac complications rate (3,5% in YG vs 26,7% in EG, p=0,001). We did not report 90-days mortality. We did not observe differences in adherence to the following ERAS steps: pre-operative carbohydrate load administration (78,7% in YG vs 76,0% in EG, p=0,7), ward transfer on POD 0 (61,7% in YG vs 48,0% in EG, p=0,32), removal of naso-gastric tube on POD 1 (87,2% in YG vs 96,0% in EG, p=0,4), resume of liquid diet on POD 1 (55,3% in YG vs 56,0% in EG, p=1), urinary catheter removal on POD 2 (61,7% in YG vs 48,0% in EG, p=0,3), fully mobilization on POD 3 (63,8% in YG vs 52,0% in EG, p=0,4), resume of soft diet on POD 4 (72,3% in YG vs 68,0% in EG, p=0,7), discharge on POD 7 (48,9% in YG vs 40,0% in EG, p=0,6). Median day of discharge was POD 8 for both groups (p= 0,8). Conclusions In high-volume centres ERAS protocols can be safely applied to elderly patients undergoing esophagectomy.

scholarly journals Evaluation of Spontaneous Swallow Frequency in Healthy People and Those With, or at Risk of Developing, Dysphagia: A Systematic Review and Meta-Analysis.

2021 ◽  
Author(s):  
Joseph M Bulmer ◽  
Caroline Ewers ◽  
Michael J Drinnan ◽  
Victoria C Ewan
Keyword(s):  
Systematic Review ◽  
At Risk ◽  
Meta Analysis ◽  
Quality Criteria ◽  
Clinical Variable ◽  
Normative Values ◽  
Healthy Population ◽  
Cochrane Central Register ◽  
Cochrane Database ◽  
Central Register

Abstract BackgroundDysphagia is a common, and frequently undetected, complication of many neurological disorders and of sarcopoenia in ageing persons. However it is difficult to detect dysphagia clinically until the point of visible aspiration, and there are relatively few trained speech and language therapists, whose time and remit are limited to those with obvious disorders. Reduction in spontaneous swallowing frequency (SSF) has been mooted as a possible proxy for dysphagia. We therefore conducted a systematic review of the literature to describe SSF in both the healthy population, and in disease specific populations, in order to assess its utility as a screening tool to identify dysphagia.MethodsWe searched Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials databases. Metadata were extracted, collated, and analysed via a random effects model to give quantitative insight.ResultsThree hundred and twelve articles were retrieved, with 19 meeting inclusion and quality criteria. Heterogeneity between studies was high (I2 = 98%), in part, due to the variety of methods for swallow identification reported. The mean SSF in Healthy younger groups was 0.98/min [CI: 0.78; 1.23]. In the Parkinson’s groups mean SSF was 0.59/min [0.41; 0.85]. Mean SSF in Healthy older, Higher risk and Dysphagic populations were similar (0.21/min [0.12; 0.37], 0.26/min [0.14; 0.85]), (0.27/min [0.17; 0.43] respectively).ConclusionsSSF is a novel, non-invasive clinical variable which warrants further explorations as to its potential to identify persons at risk of dysphagia. Larger, well-conducted studies are needed to develop objective, standardised methods for detecting SSF, and develop normative values in healthy populations.

Surgical outcomes of two different reconstruction routes for esophagectomy in esophageal cancer patients: a meta-analysis

2021 ◽  
Author(s):  
Dongqing Yan ◽  
Hongjie Zheng ◽  
Peijie Wang ◽  
Yin Yin ◽  
Qiwei Zhang ◽  
...  
Keyword(s):  
Anastomotic Leakage ◽  
Surgical Outcomes ◽  
Meta Analysis ◽  
Postoperative Mortality ◽  
Case Control ◽  
Pulmonary Complications ◽  
Anastomotic Stenosis ◽  
Cardiac Complications ◽  
Case Control Studies ◽  
Significant Difference

Summary To evaluate the effects of two different reconstruction routes (the posterior mediastinal route (PR) and the retrosternal route (RR)) on the surgical outcomes of patients after esophagectomy for esophageal carcinoma. PubMed, Embase, Web of Science and Scopus were searched from database inception to March 2021. Randomized controlled trials (RCTs) and case–control trials on the surgical outcomes of patients undergoing esophagectomy via one of the two routes were included. RevMan 5.3 software was used for the meta-analysis. In total, 19 studies were included, 8 were RCTs and 11 were case–control studies. The meta-analysis showed that among the case–control trials, the PR had reduced rates of anastomotic leakage [odds ratio (OR) = 0.56, 95% confidence interval (CI) (0.43, 0.74), P &lt; 0.01]. In addition, it had reduced rates of anastomotic stenosis [OR = 0.42, 95% CI (0.30, 0.59), P &lt; 0.01] and pulmonary complications [OR = 0.63, 95% CI (0.47, 0.84), P &lt; 0.01]. However, there was no significant difference in cardiac complications [RCTs, relative risk (RR) = 0.57, 95% CI (0.29, 1.11), P = 0.10; case–control trials, OR = 1.06, 95% CI (0.70, 1.62), P = 0.78] or postoperative mortality [RCTs, RR = 0.47, 95% CI (0.19, 1.16), P = 0.10; case–control trials, OR = 0.68, 95% CI (0.32, 1.44), P = 0.31]. Compared with the RR, the PR had reduced rates of anastomotic leakage, anastomotic stenosis and pulmonary complications.

PS01.205: FEASIBILITY OF ENHANCED RECOVERY PROTOCOL AFTER ESOPHAGEAL SURGERY IN ELDERLY PATIENTS: A SINGLE CENTRE EXPERIENCE

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 107-108
Author(s):  
Carlo Alberto De Pasqual ◽  
Jacopo Weindelmayer ◽  
Simone Giacopuzzi ◽  
Luca Alberti ◽  
Roberta La Mendola ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Conflicts Of Interest ◽  
Enhanced Recovery ◽  
High Volume ◽  
Young Group ◽  
Pulmonary Complications ◽  
Morbidity Rate ◽  
Operative Outcomes ◽  
Soft Diet ◽  
Carbohydrate Load

Abstract Background The use of ERAS (Enhanced Recovery After Surgery) protocols, to reduce morbidity and accelerate recovery is spreading in general surgery. In dedicated centres these programs have been successfully applied after oesophageal surgery. However, some concerns have been raised about the feasibility of these protocols in elderly patients. Methods We retrospective reviewed 72 patients submitted to Ivor-Lewis esophagectomy in our Institution, in the period 2015–2017. We divided the patients into two groups: 47 patients (65,3%) were < 70 years old (Young Group, YG) while 25 patients (34,7%) were ≥ 70 years old (Elderly Group, EG). We compared post-operative outcomes and adherence to ERAS steps of the two groups. Results The two groups were not different in terms of overall morbidity rate (53,2% in YG vs 60,0% in EG P = 0,6) and pulmonary complications rate (70,2% in YG vs 72,0% in EG, P = 1). We did not reporte 90-days mortality. We did not observe differences in adherence to ERAS step: pre-operative carbohydrate load administration (78,7% in YG vs 76,0% in EG, P = 0,7), peri-dural catheter for analgesia placement (89,3% in YG vs 88,0% in EG, P = 1), ward transfer on POD 0 (61,7% in YG vs 48,0% in EG, P = 0,32), removal of naso-gastric tube on POD 1 (87,2% in YG vs 96,0% in EG, P = 0,4), resume of liquid diet on POD 1 (55,3% in YG vs 56,0% in EG, P = 1), urinary catheter removal on POD 2 (61,7% in YG vs 48,0% in EG, P = 0,3), fully mobilization on POD 3 (63,8% in YG vs 52,0% in EG, P = 0,4), resume of soft diet on POD 4 (72,3% in YG vs 68,0% in EG, P = 0,7), discharge on POD 7 (48,9% in YG vs 40,0% in EG, P = 0,6). Median day of discharge was POD 8 for both groups (P = 0,8). Conclusion In high-volume centres ERAS protocols can be safely applied to elderly patients undergoing esophagectomy. An experienced team is needed to achieve this results. Disclosure All authors have declared no conflicts of interest.

scholarly journals Enhanced recovery after surgery (ERAS) protocols is extremely beneficial in liver surgeries – A metaanalysis

2020 ◽  
Author(s):  
Bhavin Vasavada ◽  
Hardik Patel
Keyword(s):  
Blood Loss ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Hospital Costs ◽  
Complete Recovery ◽  
Morbidity And Mortality ◽  
Readmission Rates ◽  
Cochrane Database ◽  
Stay Time ◽  
The Impact

ABSTRACTBACKGROUNDEnhanced recovery after surgery (ERAS) programs aim to improve postoperative outcomes.. This metaanalysis aims to evaluate the impact of ERAS programmes on outcomes following liver surgeries.METHODSEMBASE, MEDLINE, PubMed and the Cochrane Database were searched for studies comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those patients receiving conventional care. The primary outcome was occurrence of 30 day morbidity and mortality. Secondary outcomes included length of stay, functional recovery, readmission rates,time to pass flatus,blood loss and hospital costs.RESULTSTen articles were included in the metaanalysis. 30 days morbidity and mortality was significantly less in ERAS group.Hospital stay, time to pass flatus, time to complete recovery and hospital costs were also significantly reduced due to ERAS protocols. Blood loss and readmission rates were also significantly less in ERAS group.CONCLUSIONSThe adoption of ERAS protocols significantly reduced morbidity, mortality hospital stay, readmission rates, time to recovery, hospital costs, time to pass flatus, blood loss and readmission rates.

scholarly journals Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter

2016 ◽  
Vol 2016 ◽  
pp. 1-9
Author(s):  
Timothy L. Fitzgerald ◽  
Catalina Mosquera ◽  
Nicholas J. Koutlas ◽  
Nasreen A. Vohra ◽  
Kimberly V. Edwards ◽  
...  
Keyword(s):  
Enhanced Recovery ◽  
High Volume ◽  
Surgical Oncology ◽  
Readmission Rates ◽  
Before And After ◽  
The Difference ◽  
Oncology Unit ◽  
Eras Protocol ◽  
The Cost ◽  
Surgical Unit

Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.

Sign in / Sign up

Export Citation Format

Share Document