International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

Background: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. Objective: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. Study Design: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. Results: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4–11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90–0.95; P\u3c.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82–0.93; P\u3c.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P\u3c.05) among low-complexity patients. Conclusion: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation

Cost-analysis of Enhanced Recovery After Surgery (ERAS) Program in Gynecologic Surgery

Objectives. Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic sur- gery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. Methods. Retrospective study comparing perioperative costs between consecutive patient groups under- going gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. Results. Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were$13′329 (95% confidence interval (CI): 11’301-15’213) and $17’710 (95$4′381 (95% CI: 549–8’752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5’011 95Total costs continued to decrease by$2′520 (mean: $15’190, 95$3’077 (mean: $14’633, 95$5’070 (mean: $12’640, 95spectively, in year 2 and 3 after implementation. Conclusion. Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by$4’381 per patient. Total costs con- tinued to decrease in the three years after implementation

Temporary cervical sling and uterine twist before B-Lynch for massive uterine bleeding after delivery

Massive uterine bleeding occurring after delivery is in most cases unpredictable and can have fatal consequences. This article presents the technique of combining the twisting of uterus on a 90° rotation on its axis and positioning a sling around the cervix, allowing to decrease incoming blood flow from uterine and ovarian arteries. The aim of this easy-to-use procedure is to enable surgeons and anaesthesiologists to respectively ensure the presence of an experienced surgeon and to stabilise the haemodynamic of the patient. It is a modus operandi of particular interest in resources’ challenged environments

Prevalence of measured and self-reported multimorbidity in the Swiss-CoLaus population-based study

Introduction: The prevalence of multimorbidity (MM) in hospitalized patients is increasing and recognized as an important factor that may modify the strategies of treatment and increase the length of stay. Little is currently known about the prevalence of MM in the general population and if measured or self-reported diseases are different in the outpatient setting compared to hospitalized patients. The objective of the study was, therefore, to assess the prevalence of self-reported and measured MM in representative sample of the general population aged 35-75 years in Switzerland. Method: Data were obtained from the population based CoLaus Study: 3712 participants (1965 women, 50±9 years). MM was defined as presenting >=2 morbidities according to a list of 27 items (either measured or self-reported data, according to Barret et al.) or a Functional Comorbidity Index (FCI) (18 items, measured only). Results: The prevalence of MM according to these three definitions is summarized in the table 1. For all definitions prevalence of MM was higher in women, elderly participants, those with lower education levels, Swiss nationals, former smokers and obese participants. The prevalence of MM when measured data were used was significantly higher than according to self-reported (p<0.001). Multivariate analysis confirmed most of these associations, except that no difference was found for educational level and for overweight participants. Conclusion: The prevalence of MM is high in the general population, ranging from 13.8 and 50.3% even in the younger age group. The prevalence is higher in women, and increases with age and weight. The prevalence varies considerably according to the definition and is lower when using self-reported compared to measured data

Contribution of multimorbidity to overall mortality in the population-based CoLaus study

Introduction : Multimorbidity (MM) is currently a major health concern for hospitalized patients but little is known about the relative importance of MM in the general population. Accordingly we assessed whether MM could be a good predictor of overall mortality. Method : Data from the population based CoLaus Study: 3239 participants (1731 women, mean age 50+/-9 years) followed for a median time of 5.4 years (range 0.4 to 8.5 years). MM was defined as presenting >=2 morbidities according to Barnett et al. (27 items, measured data). Survival analysis was conducted using Cox regression. Results : During follow-up, 53 (1.6%) participants died. Participants who died had a higher number of morbidities (2.4 +/- 1.6 vs. 1.9 +/- 1.5, p<0.05) and had a higher prevalence of MM (69.8% vs. 55.9%, p<0.05). On bivariate analysis, presence of MM (defined as a yes/no variable) was significantly related with overall mortality: relative risk (RR) of 1.84, 95% confidence interval [1.02; 3.31], p<0.05 (see figure), but this association became non-significant after adjusting for age, gender and smoking: RR=1.68 [0.93; 3.04], p=0.09. Similar results were obtained when using the number of morbidities: RR for an extra morbidity 1.22 [1.05; 1.44], p<0.02; after adjusting for age, gender and smoking, RR=1.16 [0.99; 1.37], p=0.07. Conclusion : During a short 5 year observation period, measured MM in the general population is associated with overall mortality. This association becomes borderline significant after multivariate adjustment. These observations will have to be confirmed during a longer follow-up period. This increased mortality in MM patients may require developing specific strategies of screening and prevention

Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery

Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were$13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95$4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95$2'520 (mean: $15'190, 95$3'077 (mean: $14'633, 95$5'070 (mean: $12'640, 95Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by$4'381 per patient. Total costs continued to decrease in the three years after implementation

Anaesthesia in a Toxic Environment: Pressurised Intraperitoneal Aerosol Chemotherapy: A Retrospective Analysis

Objective: Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is a new type of intraperitoneal chemotherapy for peritoneal carcinosis via minimally invasive surgery. This technique's specificity is the remote application of the therapy because of the potential risk of exposure to toxic products. The present paper summarises the important aspects of PIPAC and analyses the anaesthetic outcomes. Methods: This retrospective study included all patients undergoing PIPAC treatment between January 2015 and February 2018. Data on protocol adherence and perioperative anaesthetic complications and postoperative nausea and vomiting (PONV) and pain levels (visual analogue scale 0-10) from recovery room to 72 h were analysed. Results: The overall analysis included 193 PIPAC procedures on 87 patients. Protocol adherence was high as regards the use of propofol (100%), rocuronium (98%), antiemetic prophylaxis (99%) and lidocaine intravenous (i.v.) (87%). No accidental exposure to chemotherapy occurred during the study period. Of the 87 patients, 6.3% suffered delayed recovery, 58% due to hypothermia and 42% due to excessive sedation or curarisation. In the recovery room, 16% of patients suffered moderate to severe pain, requiring >8 mg of morphine i.v., with average doses of 13.7 mg. Median postoperative pain scores were 1 and 3 at 12 h and 0 and 0 at 72 h at rest and mobilisation, respectively. PONV was observed in <10% of patients during the first 12 h, but in 40% at 72 h. Conclusion: A dedicated anaesthetic protocol and intraoperative safety checklist facilitates safe, well-tolerated anaesthesia for PIPAC treatments

Requirements for a successful Enhanced Recovery After Surgery (ERAS) program: a multicenter international survey among ERAS nurses

Introduction Nurses are the linchpin of any Enhanced Recovery After Surgery (ERAS) program, as they are in direct contact with patients and various caregivers. The aim of the present survey was to assess ERAS key factors and challenges from a nurse's perspective. Methods A qualitative study among ERAS dedicated nurses and ERAS Interactive Audit System (EIAS) administrators using an online questionnaire (Survey Monkey (R), Palo Alto, CA, United States) comprising 29 questions. The survey focused on challenges and drawbacks encountered during ERAS training, implementation and daily clinical practice. Closed multiple-choice and open-end questions and semantic differential scales (0-10) were used. Those invited to participate received three reminders within 4 and 8 weeks after invitation. Results Of 306 nurses invited, 123 completed the survey (response rate 40%). Overall, the success of the institutional ERAS program was rated as 6.9 +/- 2/10. Improving both patient outcomes (90%) and satisfaction (69%) were rated as main motivators for ERAS implementation, while time restraints (50%) and logistics (43%) were identified as the main barriers. The study revealed a wide heterogeneity in coordination and management strategies (ERAS meetings, work models, teaching strategies). Sustained staff education before (9.1/10) and after (9.1/10) implementation, a dedicated ERAS coordinator (8.9/10) and regular meetings (8.3/10 scale) were rated as key factors for a successful program. Difficulty of implementation, maintenance and data acquisition were all rated > 5/10. Conclusion Despite heterogeneity in coordination and management, the ERAS program is evaluated as successful from a nurse's perspective. Continuous staff education and coordination beyond the implementation period appear to be of the utmost importance for a sustained program