-
Female Pelvic Medicine & Reconstructive... Mar 2021The purpose of this analysis is to determine if postoperative opioid usage differs among women randomized to office or phone preoperative counseling for pelvic organ... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The purpose of this analysis is to determine if postoperative opioid usage differs among women randomized to office or phone preoperative counseling for pelvic organ prolapse surgery.
METHODS
This was a planned exploratory analysis of the Patient Preparedness for Pelvic Organ Prolapse Surgery study, which randomized women to standardized preoperative counseling by office visit or phone call before prolapse surgery. Inclusion criteria were the completion of the assigned counseling intervention and submission of a 7-day postoperative pain and medication diary. Multivariable logistic regression was done to assess the association between counseling method and total opioid use while controlling for variables significant on univariate analysis (surgery type and county of residence).
RESULTS
There were 84 participants with postoperative data (41 office, 43 phone). Median total number of 5-mg oxycodone tablets used was higher for the office group (5 [interquartile range, 0-10]) than the phone group (0 [interquartile range, 0-2], P = 0.002). On multivariable logistic regression, women who underwent phone counseling were less likely to be in the highest third of opioid use when controlling for surgery type and county of residence (odds ratio, 0.23; P = 0.012; 95% confidence interval, 0.07-0.72). Daily pain scores and nonopioid medication use (nonsteroidal anti-inflammatory medications and acetaminophen) were similar between groups (P > 0.05).
CONCLUSIONS
Despite similar pain scores, women who received preoperative phone counseling before pelvic organ prolapse surgery had lower opioid utilization than those with office counseling. Further research is needed to determine the optimal method of preoperative counseling and its role in postoperative pain management.
Topics: Aged; Analgesics, Opioid; Counseling; Enhanced Recovery After Surgery; Female; Humans; Middle Aged; Office Visits; Oxycodone; Pain, Postoperative; Pelvic Organ Prolapse; Preoperative Care; Telephone
PubMed: 33620901
DOI: 10.1097/SPV.0000000000001010 -
Current Opinion in Clinical Nutrition... Nov 2023Nutrition remains a key focus in the preoptimization of patients undergoing cancer surgery. Given the catabolic nature of cancer, coupled with the physiological insult... (Review)
Review
PURPOSE OF REVIEW
Nutrition remains a key focus in the preoptimization of patients undergoing cancer surgery. Given the catabolic nature of cancer, coupled with the physiological insult of surgery, malnutrition (when assessed) is prevalent in a significant proportion of patients. Therefore, robust research on interventions to attenuate the detrimental impact of this is crucial.
RECENT FINDINGS
As a unimodal prehabilitation intervention, assessment for malnutrition is the first step, as universal supplementation has not been shown to have a significant impact on outcomes. However, targeted nutritional therapy, whether that is enteral or parenteral, has been shown to improve the nutritional state of patients' presurgery, potentially reducing the rate of postoperative complications such as nosocomial infections. As part of multimodal prehabilitation, the situation is more nuanced given the difficulty in attribution of effects to the differing components, and vast heterogeneity in intervention and patient profiles.
SUMMARY
Multimodal prehabilitation is proven to improve length of hospital stay and postoperative outcomes, with nutrition forming a significant part of the therapy given. Further work is required to look at not only the interplay between the optimization of nutritional status and other prehabilitation interventions, but also how to best select which patients will achieve significant benefit.
Topics: Humans; Neoplasms; Malnutrition; Preoperative Care; Postoperative Complications; Nutritional Status; Nutrition Assessment; Length of Stay; Nutrition Therapy; Nutritional Support; Preoperative Exercise
PubMed: 37610824
DOI: 10.1097/MCO.0000000000000974 -
BMC Cancer Apr 2022Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative...
PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL).
BACKGROUND
Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients' fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs.
METHODS
This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs.
DISCUSSION
The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery.
TRIAL REGISTRATION
This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry ( ACTRN12621000617864 ) on 24th May 2021.
Topics: Abdominal Neoplasms; Australia; Exercise Therapy; Humans; Multicenter Studies as Topic; Postoperative Complications; Preoperative Care; Preoperative Exercise; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 35459100
DOI: 10.1186/s12885-022-09492-6 -
Anesthesiology Dec 2021Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors...
BACKGROUND
Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes.
METHODS
Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization.
RESULTS
The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes.
CONCLUSIONS
Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization.
Topics: Aged; Analgesics, Opioid; Cohort Studies; Female; Humans; Male; Middle Aged; Opioid-Related Disorders; Pain, Postoperative; Preoperative Care; Retrospective Studies
PubMed: 34731242
DOI: 10.1097/ALN.0000000000004026 -
BMC Anesthesiology May 2024The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed...
BACKGROUND
The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgical team and the patient, as well as guiding surgical and anesthetic planning. Certainly, preoperative tests are valuable when they offer additional information beyond what can be gathered from a patient's history and physical examination alone. Preoperative testing practices differ significantly among hospitals, and even within the same hospital, clinicians may have varying approaches to requesting tests. This study aimed to investigate preoperative testing practices and compare them with the latest guidelines from the National Institute for Health and Care Excellence (NICE).
METHODS
This three-month institutionally based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023, including individuals aged 16 years and older who were not pregnant and had undergone elective surgery in the gynecological, orthopedic, and general units. Data on the sociodemographic characteristics, the existence of comorbidities, the invasiveness of surgery, and the tests taken into consideration by the guideline were gathered using a self-administered questionnaire. After rigorously analyzing and revising the results of preoperative investigation approaches, we compared them to the standard of recommendations. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013.
RESULTS
During the data collection period, 247 elective patients underwent general, orthopedic, and gynecological operations. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one (92.71%). 350 investigations were requested in total. Of these, 71 (20.28%) tests were ordered without a justified reason or in contravention of NICE recommendations.
CONCLUSIONS
In our hospital's surgical clinical practice, unnecessary preoperative testing is still common, especially when it comes to organ function tests, electrocardiograms (ECGs), and complete blood counts (FBCs). When deciding whether preoperative studies are required, it is critical to consider aspects including a complete patient history, a physical examination, and the invasiveness of the surgery.
Topics: Humans; Elective Surgical Procedures; Female; Preoperative Care; Middle Aged; Male; Adult; Aged; Clinical Audit; Young Adult; Adolescent; Practice Guidelines as Topic; Surveys and Questionnaires
PubMed: 38783183
DOI: 10.1186/s12871-024-02557-y -
The Laryngoscope May 2021To determine the utility of preoperative penetration-aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of...
OBJECTIVES/HYPOTHESIS
To determine the utility of preoperative penetration-aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of diet after interarytenoid injection augmentation (IAIA).
STUDY DESIGN
Retrospective review.
METHODS
In this retrospective cohort study, 372 consecutive patients who underwent IAIA for pharyngeal dysphagia between 2009 and 2019 were initially identified. Patients were excluded from the study if they had insufficient preop MBS, no postop MBS within 3 months of injection, supraglottoplasty, or underlying neurological condition. Ninety-three patients were included in the study. Pre- and postoperative PAS scores were recorded, as were pre and postop diets. PAS scores were calculated by a single pediatric speech and language pathologist.
RESULTS
Average PAS score on MBS was 5.87 (standard deviation [SD] 2.74); median (range) = 8 (1-8). Postop average was 4.29 (SD 3.02); median (range) = 2 (1-8), P < .001. Those with worse preop PAS scores had increased odds of improvement in diet (odds ratio 1.24, 95% confidence interval [CI] 1.02-1.49, P = .029). An improvement in PAS score of 3.0 or greater predicted an improvement in diet with a sensitivity of 76.7% and a specificity of 85.7%.
CONCLUSIONS
PAS score on MBS can be a useful tool when assessing pediatric patients who may be candidates for IAIA. Prospectively comparing PAS score in patients post-IAIA to patients solely undergoing diet modification can help to better objectively assess differences in outcomes and understand the full utility of PAS score.
LEVEL OF EVIDENCE
Level III (Individual Cohort Study) Laryngoscope, 131:E1707-E1713, 2021.
Topics: Arytenoid Cartilage; Child, Preschool; Deglutition Disorders; Feasibility Studies; Feeding Behavior; Female; Fluoroscopy; Humans; Infant; Infant, Newborn; Injections; Laryngoscopy; Male; Predictive Value of Tests; Preoperative Care; Prognosis; Respiratory Aspiration; Retrospective Studies; Treatment Outcome
PubMed: 33009827
DOI: 10.1002/lary.29142 -
Canadian Journal of Surgery. Journal... Oct 2021Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and... (Review)
Review
Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.
Topics: Algorithms; Anemia; Evidence-Based Medicine; Humans; Hyperglycemia; Postoperative Complications; Practice Guidelines as Topic; Preoperative Care; Smoking
PubMed: 34598927
DOI: 10.1503/cjs.011519 -
Neuroimaging Clinics of North America Feb 2021Resting state functional MR imaging methods can provide localization of the language system; however, presurgical functional localization of the language system with... (Review)
Review
Resting state functional MR imaging methods can provide localization of the language system; however, presurgical functional localization of the language system with task-based functional MR imaging is the current standard of care before resection of brain tumors. These methods provide similar results and comparing them could be helpful for presurgical planning. We combine information from 3 data resources to provide quantitative information on the components of the language system. Tables and figures compare anatomic information, localization information from resting state fMR imaging, and activation patterns in different components of the language system expected from commonly used task fMR imaging experiments.
Topics: Brain; Brain Mapping; Brain Neoplasms; Humans; Image Interpretation, Computer-Assisted; Language; Magnetic Resonance Imaging; Preoperative Care; Rest
PubMed: 33220829
DOI: 10.1016/j.nic.2020.09.005 -
Chinese Clinical Oncology Feb 2024Liver resection (LR) is a commonly performed surgical procedure for the management of hepatocellular carcinoma and other liver conditions. Despite its benefits in... (Review)
Review
BACKGROUND AND OBJECTIVE
Liver resection (LR) is a commonly performed surgical procedure for the management of hepatocellular carcinoma and other liver conditions. Despite its benefits in providing patients a potential cure, it is also associated with significant postoperative complications and prolonged recovery periods. In recent years, pre-operative rehabilitation (prehabilitation) has emerged as an up-and-coming strategy to optimize patients' physical, psychological and functional status before LR, leading to improved surgical and patient postoperative outcomes. Hence, our review aims to explore and synthesize the existing literature on prehabilitation in LR to provide an overview of the current evidence to help guide physicians in managing their patients.
METHODS
A comprehensive literature search was conducted in multiple electronic databases from inception to July 2023. The search strategy was tailored to capture studies investigating the role of prehabilitation in LR, and the factors that contribute to beneficial outcomes in the postoperative period.
KEY CONTENT AND FINDINGS
Prehabilitation programs encompass a multifaceted approach to enhance surgical outcomes and patient well-being. This considers the specific needs of the varying patient populations, such as the elderly, or the cancer ridden. Improving physical fitness, nutritional supplementation and psychological support are the common tenets of prehabilitation. In physical prehabilitation, patients are engaged in intensive physical exercise often by means of a cycle ergometer. Addressing nutritional deficiencies through supplements and dietary interventions is also vital. Psychosocial assessments, advance care planning, music therapy, and progressive relaxation exercises are shown to enhance patient resilience and well-being. In addition, innovative approaches such as optimizing fluid balance, avoiding epidural analgesia, perioperative steroid administration, phosphate correction and branched-chain amino acid supplementation are being explored.
CONCLUSIONS
Prehabilitation is important in optimizing patients before LR and is key in improving postoperative outcomes. Several prehabilitation strategies exist, but no formal consensus exists on patient selection and an ideal program.
Topics: Humans; Aged; Preoperative Exercise; Preoperative Care; Postoperative Complications; Hepatectomy; Liver
PubMed: 38372059
DOI: 10.21037/cco-23-102 -
Hand (New York, N.Y.) Sep 2019The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling...
The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, = 0.005) and 5 or more total encounters (80%, = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon ( = 0.267) or medical office encounters ( = 0.087), or a patient's perceived health status ( = 0.14). Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.
Topics: Aged; Elective Surgical Procedures; Female; Hand; Humans; Male; Middle Aged; Orthopedic Procedures; Patient Satisfaction; Preoperative Care; Surveys and Questionnaires
PubMed: 29504474
DOI: 10.1177/1558944718760036