Implementing Enhanced Recovery Pathways: a literature review with realist synthesis

Objectives: Enhanced Recovery Pathways (ERPs) are an increasingly popular, evidenced-based approach to surgery, designed to improve patient outcomes and reduce costs. Despite evidence demonstrating the benefits of these pathways, implementation and adherence have been inconsistent. Methods: Using realist synthesis, this review explored the current literature surrounding the implementation of ERPs in the UK. Knowledge consolidation between authors and consulting with field experts helped to guide the search strategy. Relevant medical and social science databases were search from 2000 to 2016, as well as a general web search. A total of 17 papers were identified, including original research, reviews, case studies and guideline documents. Full texts were analysed, cross-examined, and data extracted and synthesised. Results: Several implementation strategies were identified, including the contexts in which these operated, the subsequent mechanisms of action that were triggered, and the outcome patterns they produced. Context-Mechanism-Outcome (CMO) configurations were generated, tested, and refined. These were grouped to develop two programme theories concerning ERP implementation, one related to the strategy of consulting with staff, the other with appointing a change agent to coordinate and drive the implementation process. These theories highlight instances in which implementation could be improved. Conclusion: Current literature in ERP research is primarily focussed on measuring patient outcomes and cost effectiveness, and as a result, important detail regarding the implementation process is often not reported or described robustly. This review not only provides recommendations for future improvements in ERP implementation, but also highlights specific areas of focus for furthering ERP implementation research

The prognostic influence of bcl-2 in malignant glioma

The bcl-2 gene is one of a complex group of genes which control programmed cell death. Bcl-2 acts to extend cell survival by blocking apoptosis, and thereby may influence tumour prognosis. This study of 187 high grade gliomas reviews clinicopathological prognostic features and the relationship to bcl-2 expression. Bcl-2 immunostaining was assessed in 159 specimens from these patients, by scoring systems of 0 to 3 for intensity of scoring and proportion of cells staining. Age, histology, pre- and post-operative performance status were found to be strongly predictive of survival (log rank test P<0.0001). The type of surgery performed did not influence survival in this group of patients. The expression of bcl-2 had a significant relationship with survival (univariate Cox model P=0.0302, hazard ratio 0.8, 95% confidence interval 0.65–0.98), with increased staining associated with improved survival. Multivariate analysis showed performance status, histology and proportion of cells staining for bcl-2 to be independently predictive of survival. Bcl-2 staining was not related to histological grade of tumours

The role of CT in predicting the surgical feasibility of exenteration in recurrent carcinoma of the cervix

In women with recurrent cervical cancer, there is a 52% 5-year survival rate when exenteration of the centrally placed tumor is performed. If not exenterated, the 2-year survival rate is less than 2%. The purpose of this study is to ascertain whether CT can predict inoperability reliably leading to a reduction in operations which do not have a curative outcome. The records of patients with recurrence of cervical cancer who underwent laparotomies for exenteration over the last 10 years under the care of one surgeon were reviewed. The CT scans were retrospectively assessed by two radiologists without knowledge of the subsequent outcome of the laparotomy. CT scans on 31 patients were reviewed, 21 of whom underwent a radical surgical procedure. Using CT criteria, 9 cases were felt to be operable with a curative intent and the remaining 22 cases were deemed to be inoperable. The sensitivity of CT prediction of inoperability is 93% (95%Cl:66-100%) and the specificity is 47% (95%Cl:23-72%). In three cases ascites was the only abnormal finding other than the central pelvic mass and in all of these cases a radical procedure with clear resection margins was possible. When the group with ascites alone was not considered to have peritoneal disease underlying the ascites, the sensitivity of CT prediction of inoperability is 93% (95%Cl:66-100%) and the specificity of 65% (95% Cl:38-86%). If, in addition, lymphadenopathy is not taken as definite evidence of inoperability, the specificity rises to 82% (95%Cl:57-96%). A high quality CT scan is highly specific for predicting inoperability based on extension of the tumor to the pelvic side walls, encasement of adjacent vessels or ureteric dilatation and so should be a major tool in assessing women for radical surgical treatment of recurrent cervical cancer. If ascites is the only abnormal finding other than the central pelvic mass then exploration should be undertaken.link_to_subscribed_fulltex