Prognostic factors influencing infectious complications after cytoreductive surgery and HIPEC. Results from a tertiary referral center

Background. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC. Methods. For the study we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers and treated by CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) in group A (well-nourished), B/C (mild or severely malnourished). Possible statistical correlations between risk factors and postoperative complications rates have been investigated by univariate and multivariate analysis. Results. Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients and 53% in SGA-B /C patients. Cause of complications was infective in 42, non-infective in 37 and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B /C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were Surgical Site Infections (SSI, 35.7%) and Central Line Associated BloodStream Infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels and nutritional status correlated with higher risk for postoperative infectious complications. Conclusions. Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to post-operative infectious complications and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce complications rate

Experiences of the Postoperative Recovery Process: An Interview Study

Few researchers have described postoperative recovery from a broad, overall perspective. In this article the authors describe a study focusing on patient and staff experiences of postoperative recovery using a qualitative descriptive design to obtain a description of the phenomenon. They performed 10 individual interviews with patients who had undergone abdominal or gynecological surgery and 7 group interviews with registered nurses working on surgical and gynecological wards and in primary care centers, surgeons from surgical and gynecological departments, and in-patients from a gynecological ward. The authors analyzed data using qualitative content analysis. Postoperative recovery is described as a Dynamic Process in an Endeavour to Continue With Everyday Life. This theme was further highlighted by the categories Experiences of the core of recovery and Experiences of factors influencing recovery. Knowledge from this study will help caregivers support patients during their recovery from surgery

Impact of Nursing Education on Postoperative Ileus Prevention in a Tertiary Care Facility: A Quality Improvement Project

Postoperative ileus (POI) is a preventable but potentially fatal complication that affects approximately 10% to 30% of patients who undergo major abdominal surgery. Despite the use of Enhanced Recovery After Surgery (ERAS) protocols, tertiary care facilities continue to struggle with this complication affecting not only patient outcomes but also healthcare cost and revenue generation. Although hospitals often offer general education to staff nurses throughout the year, the topics are mainly designed to target national accreditation requirements. This leaves a knowledge gap on specific skills and interventions that could greatly improve health outcomes. To address this issue, a quality improvement project to increase nurse knowledge of POI was implemented in an acute tertiary care facility in the Miami area. A total of 43 registered nurses working in two inpatient step-down units were included in this project. The results were analyzed and a significant increase in mean scores for knowledge and confidence before and after the education intervention were noted. Overall, there was a 34% increase in mean confidence self-assessment score and a 109% increase in knowledge mean scores when compared to baseline. Although a power analysis was not performed, a paired one-tailed t-test was executed to determine statistical significance showing a result of p \u3c 0.0001. The data shows that nurse education is effective at enhancing knowledge and confidence when identifying, preventing, and treating POI. Based on the evidence and the results of this project, future education should be implemented and the material incorporated into onboarding curriculums for surgical units

Telephone Follow-Up to Reduce the Readmission Rate in Gynecologic Oncology Surgery Patients

Unplanned hospital readmissions are commonly viewed as a marker of poor quality care and result in increased costs for both healthcare institutions and patients. Factors associated with readmission for gynecological oncology patients can be related to the radical surgical interventions required for the management of their disease, as well as complex comorbidity profiles, surgical complexity, cancer stage, and perioperative complications. The purpose of this study was to explore and examine the impact of nursing-led telephone follow up on the reduction of the readmission rate in gynecologic oncology abdominal surgery patients following initial discharge post-operatively. A cross-sectional research study was used to examine the relationship between the use of post discharge follow-up calls (intervention group versus control group) and 30-day readmission (yes/no) using chi-squared test for all categorical variables, and two sample t-tests for continuous variables. Variables were compared between the experimental and control groups given the potential association with the outcome of interest (readmission), including age, body mass index (BMI), comorbidities, tobacco use, performance status using the Eastern Cooperative Oncology Group (ECOG) status, length of surgery, estimated blood loss, perioperative blood transfusion, formation of ostomy, and length of hospital stay of one day or greater than one day duration. There were no significant differences found between the control group and experimental groups and each variable. There are future implications of this study surrounding the profound importance of the involvement of nursing staff in improvement in discharge teaching, transitions of care, and the patient experience. Evidenced-based practices are needed to improve the health and safety of the patients we care for

Mobilization immediately after elective abdominal surgery : respiratory effects and patients´ and healthcare professionals´ experiences

To prevent postoperative complications after abdominal surgery, mobilization is highly recommended and suggested to start as soon as possible. However, few studies have investigated the respiratory effects of immediate postoperative mobilization among patients undergoing elective open or robot-assisted laparoscopic abdominal surgery. Nor have patients´ and healthcare professionals´ experiences of such an early mobilization procedure been investigated. Participants in study I to III were recruited from an out-patient pre-anesthesia clinic at Karolinska University Hospital Solna, Stockholm. For paper IV, the participants were recruited from the postoperative recovery unit at the same hospital. Paper I was a 3-armed RCT, consecutively including 214 patients who underwent elective open or robot-assistedlaparoscopic gynecological, urological, or endocrinological abdominal surgery with ananesthetic duration of >2 hours. Patients were randomized to mobilization only (to sit in a chair) (n = 76), mobilization (to sit in a chair) in combination with breathing exercises (n = 73), or to be controls (no treatment) (n = 65). The interventions started within 2 hours after arrival at the postoperative recovery unit. The results showed that compared with the controls, SpO2 and PaO2 improved for patients in the intervention groups. Paper II was a secondary analysis of data from the RCT including the patients who were assigned to and complied with the mobilization interventions (n = 137). Mobilization initiation time and duration of mobilization were investigated in relation to SpO2 and PaO2. The results indicated that mobilization within the first hour after surgery was not superior to being mobilized within the second hour regarding SpO2 and PaO2. Further, SpO2 and PaO2 were similar between the groups irrespective of whether the patients were mobilized for less than 30 minutes, between 30 and 90 minutes, or longer than 90 minutes. Paper III included face-to-face interviews with 23 patients who were randomized to one of the mobilization interventions. The overarching theme that emerged from the content analysis was “To do whatever it takes to get home earlier”, which was built on the three categories; “The impact of mobilization”, “To feel safe and be confident with the mobilization process”, and “Experiences and motivational factors”. Paper IV, was an interview study of 17 healthcare professionals who had been involved in mobilization of patients in the RCT. The interviews were analyzed with content analysis and resulted in the overarching theme “A changed mindset” which represented a turning point when the healthcare professionals observed that mobilization was safe and beneficial for the patients, and their safety concerns were reduced. The overall conclusion of this thesis was that mobilization immediately after abdominal surgery improved SpO2 and PaO2. Initiation time and duration of mobilization seemed to be of less importance. Patients found that it improved their physical and mental well-being. The healthcare professionals ‘experienced the postoperative recovery unit was a safe place for initiating mobilization as long as they had access to sufficient resources and a wellfunctioning multiprofessional team of nurses, assistant nurses and physiotherapists

Individualized laparoscopic and related technique in rectal cancer surgery

[Extract from Preface] The main studies listed in each chapter were carefully selected as to reflect the critical knowledge essential in each of the important steps to overcome the main challenges toward the success in achieving the best possible outcomes in rectal cancer patient care. However, the main original contribution of the thesis was demonstrated clearly in "Chapter 3: Laparoscopic surgery for rectal cancer" where the proposed laparoscopic pull-through with coloanal anastomosis was highlighted. The chapter showed a prospective comparative study comparing all aspects of the two techniques; laparoscopic ultralow anterior resection versus laparoscopic pull-through with coloanal anastomosis for rectal cancers. All the published studies involved in each chapter of the thesis were carefully illustrated in their original format with my great respect to the international peer-review. Nevertheless, each chapter contained the overview aiming to state the connectivity of the ideas for each specific detail contained in each chapter. Despite the fact that the majority of the studies were conducted in high-volume, specialized centers, it was a real challenge to organize prospective studies for highly specific research questions over the limited time of my doctorate degree study. Chapter Overview. Chapter 1: Introduction. This chapter described the context of this research; why rectal cancer treatment is challenging; impact of multidisciplinary treatment on the outcomes. Chapter 2: Overview in colorectal cancer treatment. To review of role of various treatment modalities and variations to optimise both short-term and long-term outcomes; Hiranyakas A, Yik Hong H. Surgical Treatment of Colorectal Cancer – a Review. Int Surg. 2011; 96(2):120-6. Chapter 3: Laparoscopic surgery for rectal cancer. To discuss and propose appropriate laparoscopic techniques / approaches in the challenging surgical conditions to achieve the best possible outcomes; Hiranyakas A, Yik Hong H. Laparoscopic Ultralow Anterior Resection Versus Laparoscopic Pull-through with Coloanal Anastomosis for Rectal Cancers – a Comparative Study. Am J Surg. 2011; 202(3):291-7. Chapter 4: Factors influencing rectal cancer treatment outcomes. To discuss and propose the factors influencing the optimal outcomes for rectal cancer treatment; Hiranyakas A, Yik-Hong H, da Silva, GM, Wexner SD, Allende D, Berho M. Factors Influencing Circumferential Resection Margin in Rectal Cancer. Colorectal Dis. 2013 ;15(3):298-303. Chapter 5: Technique to avoid postsurgical complication. To discuss and propose surgical techniques essential in avoiding serious postsurgical consequences; Hiranyakas A, da Silva GM, Denoya P, Shawki S, Wexner SD. Colorectal Anastomotic Stricture: Is it associated with inadequate Colonic Mobilization? Tech Coloproctol. 2013 ;17(4):371-5. Chapter 6: Protocols for rapid recovery. To discuss in depth for the appropriate immediate postsurgical-care protocols to achieve the smooth and rapid recovery (among the most common diseased population); Hiranyakas A, Bashankaev B, Seo CJ, Khaikin M, Wexner SD. Epidemiology, Pathophysiology and Medical Management of Postoperative Ileus in the Elderly. Drugs Aging. 2011; 28(2):107- 18. Chapter 7: Closure of the ileostomy. To discuss and propose the necessity of certain surgical procedures to enhance optimal immediate postsurgical outcomes in low rectal cancer patients; Hiranyakas A, Rather A, da Sliva GM, Wexner SD, Weiss EG. Loop ileostomy Closure after Laparoscopic vs. Open Surgery: Is There a Difference? Surg Endosc. 2013 ;27(1):90-4. Chapter 8: Treatment of common stomal complication. To discuss and propose minimally invasive surgical approaches in the treatment of the common stomal consequence; Hiranyakas A, Yik Hong H. Laparoscopic Parastoma Hernia Repair, Multi-media Article. Dis Colon Rectum 2010; 53(9):1334-6. Chapter 9: Conclusion, outcomes and future research directions. This chapter gives the conclusions from the studies and proposes future research directions

Survival as a clinical outcome and its spiritual significance in a cohort of patients with advanced central pelvic neoplastic disease undergoing total pelvic evisceration: a poorly debated issue

Background Patients with either treatment-resistant or relapsing advanced central pelvic neoplastic disease present with a condition responsible for debilitating symptoms and consequently poor quality of life (QoL). For these patients, therapeutic strategies are very limited and total pelvic evisceration is the only option for relieving the symptoms and increasing survival. Of note, taking charge of these patients cannot be limited to increasing their lifespan but must also be aimed at improving the clinical, psychological, and spiritual conditions. This study aimed to prospectively evaluate the improvement in survival and QoL, focusing on spiritual wellbeing (SWB), in patients with poor life expectancy who underwent total pelvic evisceration for advanced gynecological cancers at our center. Patients and methodsThe QoL and SWB were assessed using the European Organisation for Research and Treatment of Cancer QoL questionnaire (EORTC QLQ-C30), EORTC QLQ-SWB32, and SWB scale, which were repeatedly administered: 30 days before surgery, 7 days after the procedure, 1 and 3 months after surgery, and then every 3 months until death or the last follow-up assessment. Operative outcomes (blood loss, operative time, hospitalization, and incidence of complications) were evaluated as secondary endpoints. The patients and their families were included in a dedicated psycho-oncological and spiritual support protocol, which was managed by specifically trained and specialized personnel who accompanied them during all phases of the study. ResultsA total of 20 consecutive patients from 2017 to 2022 were included in this study. Of these patients, 7 underwent total pelvic evisceration by laparotomy and 13 underwent laparoscopy. The median survival was 24 months (range: 1-61 months). After a median follow-up of 24 months, 16 (80%) and 10 patients (50%) were alive at 1 year and 2 years after surgery, respectively. The EORTC-QLQ-C30 scores significantly improved yet at 7 days and at 1, 3, 6, and 12 months, as compared with the preoperative values. In particular, an early improvement in pain, overall QoL, and physical and emotional functions was observed. With respect to the SWB, the global SWB item score of the EORTC QLQ-SWB32 questionnaire significantly increased after 1 month and 3 months, as compared with preoperative values (p = 0.0153 and p = 0.0018, respectively), and remained stable thereafter. The mean SWB scale score was 53.3, with a sense of low overall SWB in 10 patients, a sense of moderate SWB in eight patients, and a sense of high SWB in two patients. The SWB scale score significantly increased after 7 days, 1 month, and 3 months, as compared with the preoperative value (p = 0202, p = 0.0171, and p = 0.0255, respectively), and remained stable thereafter. ConclusionTotal pelvic evisceration is a valid approach for improving both survival and QoL in selected patients with advanced pelvic neoplasms and poor life expectancy. Our results particularly underline the importance of accompanying the patients and their families during the journey with dedicated psychological and spiritual support protocols

The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review

Background: Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent.Aim: To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. Design: The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. Data sources: Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. Results: A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. Conclusions: Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment ‘success’ that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population