Impacto de un programa de recuperación intensificada en cistectomía radical. Estudio comparativo de cohortes

Objetivo: Evaluar los resultados de la instauración de un programa de recuperación intensificada (ERAS) para cistectomía radical en abordaje abierto con respecto a la cohorte histórica de un mismo hospital. Material y métodos: Estudio de análisis retrospectivo de 138 pacientes sometidos a cistectomía radical con derivación ileal tipo Bricker o Studer de forma consecutiva (97 históricos vs. 41 ERAS). Se compararon tasa de complicaciones a 30 días, complicaciones estadio Clavien-Dindo > 2, mortalidad, estancia y tasa de readmisión en el hospital y en cuidados críticos, reintervención y necesidad de sondaje nasogástrico, trasfusión o nutrición parenteral. Resultados: No se hallaron diferencias estadísticamente significativas en cuanto a la tasa de complicaciones globales tras 30 días de alta (73,171 vs. 77.32%; OR 1,25, IC 95% 0,54-2,981; p = 0,601) ni en Clavien-Dindo > 2 (41,463 vs. 42.268%; OR 1.033, IC 95% 0,492-2,167; p = 0,93), así como en mortalidad, estancias o tasas de readmisión y reintervención. La necesidad de sondaje nasogástrico fue menor en el grupo ERAS (43,902 vs. 78,351%; OR 4,624, IC 95% 2,112-10,123; p < 0,0001), así como la necesidad de nutrición parenteral total (26,829 vs. 34,021%; OR 12,234, IC 95% 5,165-28,92; p < 0,0001) y el tiempo bajo intubación orotraqueal desde la inducción anestésica (mediana [RIC] = 325 (285-355) vs. 540 (360-600) min; p < 0,0001). Conclusión: Los programas de recuperación intensificada en cistectomía radical disminuyen el intervencionismo sobre el paciente sin aumentar la morbimortalidad

Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial)

Background The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor-guided goal-directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. Methods The FEDORA trial was a prospective, multicentre, randomised, parallel-group, controlled patient- and observer-blind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min−1 m−2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. Results In total, 450 patients were randomized to the GDHT group (n=224) or control group (n=226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P=0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. Conclusions Oesophageal Doppler monitor-guided GDHT reduced postoperative complications and hospital length of stay in low–moderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days

Aceleração da recuperação após protocolo cirúrgico versus cuidados perioperatórios convencionais em cirurgia colorretal. Um estudo de coorte em centro único [Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]

Justificativa: O protocolo ERAS – do Inglês Enhanced Recovery After Surgery – consiste em um conjunto de medidas perioperatórias destinadas a melhorar a recuperação do paciente e diminuir o tempo de internação e as complicações pós-operatórias. Avaliamos a implantação e os resultados de um protocolo ERAS para cirurgia colorretal. Métodos: Estudo observacional em centro único. Os dados foram coletados de pacientes consecutivos submetidos à cirurgia colorretal aberta ou laparoscópica durante dois períodos: três anos antes (pré-ERAS) e dois anos após (pós-ERAS) a implantação de um protocolo ERAS. As características basais de ambos os grupos foram comparadas. O desfecho primário foi o número de pacientes com 180 dias de acompanhamento com complicações moderadas ou graves. Os desfechos secundários foram tempo de internação pós-cirurgia e complicações específicas. Os dados foram extraídos de prontuários dos pacientes. Resultados: O grupo pré-ERAS foi composto por 360 pacientes e o grupo pós-ERAS por 319. No grupo pré ERAS, 214 pacientes (59, 8%) desenvolveram pelo menos uma complicação versus 163 (51, 10%) no grupo pós-ERAS. Um número maior de pacientes do grupo pré-ERAS desenvolveu complicações moderadas ou graves (31, 9% vs. 22, 26%, p = 0, 009); e complicações graves (15, 5% vs. 5, 3%; p < 0, 0001). A mediana do tempo de internação foi de 13 (17) dias no grupo pré-ERAS e de 11 (10) dias no grupo pós-ERAS (p = 0, 034). Não houve diferença nas taxas de mortalidade (4, 7% vs. 2, 5%; p = 0, 1554) ou de reinternação (6, 39% vs. 4, 39%; p = 0, 31). A conformidade geral do protocolo ERAS na coorte pós-ERAS foi de 88%. Conclusões: A implantação do protocolo ERAS para cirurgia colorretal foi associada a uma redução significativa das complicações pós-operatórias e do tempo de internação. Background: Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods: Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results: There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions: The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay