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Journal of Visceral Surgery Apr 2019In a majority of cases, enhanced recovery after surgery program (ERP) leads to a reduced rate of postoperative complications and shortened hospital stays following...
INTRODUCTION
In a majority of cases, enhanced recovery after surgery program (ERP) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery. The program's preoperative, perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team. Having shown its merits in digestive surgery, ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail. The objective of this review was to evaluate the efficacy of ERP in liver surgery.
METHOD
This is a systematic narrative review of the literature on the efficacy of ERP in liver surgery by laparotomy or laparoscopy.
RESULTS
Notwithstanding a number of studies (n=30: 5 randomized trials, 14 cohort studies and 11 meta-analyses) less sizable than with regard to digestive surgery in general and colorectal surgery in particular, analysis of the literature confirms that in liver surgery, ERP is associated with an overall decrease in complications by 30 to 60%, but without improvement in the rates of hospital readmission and postoperative mortality. All of the studies report a reduction in average length of stay (ALOS) by 2.3 days and in functional recovery, a more objective indicator than ALOS, by 2.5 days. As of now, the economic impact of the ERP programs in liver surgery is neither positive nor negative, the above-mentioned savings being counterbalanced by heightened costs for material and equipment. Laparoscopic surgery is independently associated with better outcomes in terms of complications, functional recovery and ALOS; that is why it is important to incorporate this surgical approach in ERP as often as possible. Given a lack of robust evidence, Prehabilitation, which is a preoperative optimization process leading to improved functional reserve, has yet to be assigned a place in ERP programs pertaining to liver surgery. Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader, a motivated multidisciplinary team, training courses and dedicated teaching sessions.
CONCLUSION
ERP is a care improvement process that has a major play to play in organization of liver surgery, and its large-scale application is to be recommended.
Topics: Cost Savings; Enhanced Recovery After Surgery; Hepatectomy; Humans; Laparoscopy; Laparotomy; Length of Stay; Liver; Patient Readmission; Postoperative Complications; Program Development; Recovery of Function
PubMed: 30447936
DOI: 10.1016/j.jviscsurg.2018.10.007 -
Canadian Journal of Anaesthesia =... Nov 2023Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. Although the evidence suggests that beta blockers prevent POAF, they often... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. Although the evidence suggests that beta blockers prevent POAF, they often cause hypotension. Landiolol, an ultra-short-acting β blocker, may prevent POAF, without adverse hemodynamic consequences.
SOURCE
We searched MEDLINE, CENTRAL, Embase, and trial registries between January 1970 and March 2022. We included randomized controlled trials (RCTs) that evaluated the effect of landiolol for the prevention of POAF after cardiac surgery. Two reviewers independently assessed eligibility, extracted data, and assessed risk of bias using the Risk of Bias 2.0 tool. We pooled data using random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations framework to assess certainty of evidence.
PRINCIPAL FINDINGS
Nine RCTs including 868 participants met the eligibility criteria. Patients randomized to landiolol (56/460) had less POAF compared with controls (133/408) with a relative risk (RR) of 0.40 (95% confidence interval [CI], 0.30 to 0.54; I = 0%;) and an absolute risk of 12.2% vs 32.6% (absolute risk difference, 20.4%; 95% CI, 15.0 to 25.0). Landiolol resulted in a shorter hospital length-of-stay (LOS) (268 patients; mean difference, -2.32 days; 95% CI, -4.02 to -0.57; I = 0%). We found no significant difference in bradycardia (RR, 1.11; 95% CI, 0.48 to 2.56; I = 0%). No hypotension was reported with landiolol. We judged the certainty of evidence as moderate for POAF (because of indirectness as outcomes were not clearly defined) and low for LOS (because of imprecision and concern of reporting bias).
CONCLUSION
In patients undergoing cardiac surgery, landiolol likely reduces POAF and may reduce LOS. A definitive large RCT is needed to confirm these findings.
STUDY REGISTRATION
PROSPERO (CRD42021262703); registered 25 July 2021.
Topics: Humans; Atrial Fibrillation; Postoperative Complications; Cardiac Surgical Procedures; Morpholines; Randomized Controlled Trials as Topic
PubMed: 37917331
DOI: 10.1007/s12630-023-02586-0 -
BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
Annals of Palliative Medicine Oct 2021In clinical general thoracic surgery, the prevalence of atelectasis is relatively high. Perioperative interventions can affect the probability of patients with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In clinical general thoracic surgery, the prevalence of atelectasis is relatively high. Perioperative interventions can affect the probability of patients with atelectasis after surgery. Therefore, the incidence of perioperative intervention to prevent atelectasis after thoracic surgery was discussed using meta-analysis in this study.
METHODS
The articles were searched in the English database PubMed and Chinese databases including China National Knowledge Infrastructure (CNKI), VIP, and China Journal Full-text Database (CJFD). The duration for publication time of the articles was from the database inception to March 2021, and the articles were required to be randomized controlled trials (RCTs) using interventions [such as changing the dose of general anesthesia, continuous positive end expiratory pressure (PEEP), non-invasive pressure support ventilation, and physical therapy] after thoracic surgery (such as pulmonary lobectomy, sternum surgery, and lung cancer surgery) for the treatment of atelectasis. The software RevMan 5.3 provided by the Cochrane Collaboration was used for meta-analysis.
RESULTS
A total of 5 articles were obtained, including 375 cases in the control group and 268 cases in the intervention treatment group. A meta-analysis was performed on the included articles, combined effect model analysis results showed that compared with the control group, the use of PEEP during mechanical ventilation can significantly reduce the incidence of atelectasis [odds ratio (OR) =0.46; 95% confidence interval (CI): 0.31-0.67; Z=3.94; P<0.0001].
DISCUSSION
Perioperative intervention was more effective for postoperative atelectasis and other complications.
Topics: Humans; Positive-Pressure Respiration; Postoperative Complications; Pulmonary Atelectasis; Thoracic Surgery; Thoracic Surgical Procedures
PubMed: 34763434
DOI: 10.21037/apm-21-2441 -
Scandinavian Journal of Gastroenterology Oct 2016Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded... (Review)
Review
BACKGROUND
Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.
METHODS
A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.
RESULTS
A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.
CONCLUSIONS
Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
Topics: Digestive System Surgical Procedures; Drainage; Humans; Morbidity; Pancreas; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27216233
DOI: 10.3109/00365521.2016.1169317 -
European Urology Jul 2016Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and... (Review)
Review
CONTEXT
Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times.
OBJECTIVE
To overview the use and key elements of ERAS pathways, and define needs for future clinical trials.
EVIDENCE ACQUISITION
A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery."
EVIDENCE SYNTHESIS
We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters.
CONCLUSIONS
ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery.
PATIENT SUMMARY
This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.
Topics: Diet; Early Ambulation; Perioperative Care; Postoperative Complications; Recovery of Function; Smoking Cessation; Time Factors; Urologic Surgical Procedures
PubMed: 26970912
DOI: 10.1016/j.eururo.2016.02.051 -
Laeknabladid Jun 2015Delirium is a sudden and usually transient disturbance in consciousness, attention, cognition, perception and emotions. The pathophysiology is unknown but possible... (Review)
Review
Delirium is a sudden and usually transient disturbance in consciousness, attention, cognition, perception and emotions. The pathophysiology is unknown but possible causes include neurotransmitter disturbances and inflammation reaction. Delirium is common in patients after open cardiac surgeries and can lead to serious consequences. Research shows that delirium is an underdiagnosed and undertreated problem. The purpose of this systematic review is to illuminate the prevalence, risk factors and outcome of postoperative delirium following open cardiac surgery. A systematic literature review from 2005-2013 was performed aiming to determine the prevalence, predisposing and precipitating factors and outcome after postoperative delirium following cardiac surgery. Web of Science, PubMed and Cinahl were searched. Findings of the systematic review shows that about one third of patients become delirious after cardiac surgery. Primary predisposing factors are advanced age, cognitive impairment, atrial fibrillation, depression and prior history of stroke. Among precipitating factors are pulmonary bypass, duration of mechanical ventilation, low cardiac output, respiratory failure, pneumonia, infections, blood cell transfusion and post-operative arrhythmias. Delirium causes prolonged hospital stay, reduced activity and higher mortality. Delirium prevention includes reducing risk factors. Delirium is a common and serious complication of open cardiac surgery. Knowledge of risk factors of delirium and regular screening for symptoms of delirium are important to reduce prevalence and to facilitate diagnosis and treatment.
Topics: Cardiac Surgical Procedures; Delirium; Humans; Prevalence; Prognosis; Risk Factors; Time Factors
PubMed: 26158535
DOI: 10.17992/lbl.2015.06.31 -
Fenoldopam to prevent acute kidney injury after major surgery-a systematic review and meta-analysis.Critical Care (London, England) Dec 2015Acute kidney injury (AKI) after surgery is associated with increased mortality and healthcare costs. Fenoldopam is a selective dopamine-1 receptor agonist with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute kidney injury (AKI) after surgery is associated with increased mortality and healthcare costs. Fenoldopam is a selective dopamine-1 receptor agonist with renoprotective properties. We conducted a systematic review and meta-analysis of randomised controlled trials comparing fenoldopam with placebo to prevent AKI after major surgery.
METHODS
We searched EMBASE, PubMed, meta-Register of randomised controlled trials and Cochrane CENTRAL databases for trials comparing fenoldopam with placebo in patients undergoing major surgery. The primary outcome was incidence of new AKI. Secondary outcomes were requirement for renal replacement therapy and hospital mortality.
RESULTS
Eighty-three publications were screened; 23 studies underwent full data extraction and scoring. Six trials were suitable for inclusion in the data synthesis (total of 507 subjects undergoing cardiovascular surgery, partial nephrectomy, liver transplant surgery). Five studies were rated at high risk of bias. Data on post-operative incidence of AKI were available in five of the six trials (total of 471 patients) but definitions of AKI varied between studies. Of the 238 patients receiving fenoldopam, 45 (18.9%) developed AKI compared to 62 (26.6%) of the 233 patients who received placebo (p = 0.004, I (2) = 0 %; random-effects model odds ratio 0.46, 95% confidence interval 0.27-0.79). In patients treated with fenoldopam, there was no difference in renal replacement therapy (n = 478; p = 0.11, I (2) = 47%; fixed-effect model odds ratio 0.27, 95% confidence interval 0.06-1.19) or hospital mortality (p = 0.60, I (2) = 0 %; fixed-effect model odds ratio 1.0, 95% confidence interval 0.14-7.37).
CONCLUSIONS
In this analysis, peri-operative treatment with fenoldopam was associated with a significant reduction in post-operative AKI but it had no impact on renal replacement therapy or hospital mortality. Equipoise remains for further large trials in this area since the studies were conducted in three types of surgery, the majority of studies were rated at high risk of bias and the criteria for AKI varied between trials.
Topics: Acute Kidney Injury; Fenoldopam; Hospital Mortality; Humans; Surgical Procedures, Operative
PubMed: 26703329
DOI: 10.1186/s13054-015-1166-4 -
BioMed Research International 2015To investigate the effectiveness and safety of controlled venous pressure in liver surgery and further to compare the clinical outcomes of low central venous pressure by... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate the effectiveness and safety of controlled venous pressure in liver surgery and further to compare the clinical outcomes of low central venous pressure by infrahepatic inferior vena cava clamping (IVCC) and intraoperative anesthetic control (IAC).
METHODS
Online databases including PubMed, Embase, Cochrane Library, Clinical trials.gov, and China biology medicine database were comprehensively searched. After identifying relevant studies out of the search results, quality assessment was performed according to the methods recommended by the Cochrane collaboration. And meta-analysis was performed by both direct comparison and indirect comparison.
RESULTS
Thirteen studies containing 1252 patients were included. Compared with control, controlled venous pressure significantly decreased central venous pressure, total blood loss, blood loss during transection, transfusion rate, and total incidence of complications. Further analysis of IVCC and IAC showed that there was no significant difference in aspects of main clinical outcomes.
CONCLUSIONS
Controlled venous pressure significantly decreased central venous pressure and achieved improvement of bleeding control in liver surgery. It reduced total incidence of complications and chest infection, while it caused concerns about heart disorder. Although IVCC was not worse than IAC in therapeutic effect, a superiority between them still needs to be explored.
Topics: Anesthesia; Blood Loss, Surgical; Central Venous Pressure; Constriction; Digestive System Surgical Procedures; Humans; Liver; Safety; Treatment Outcome; Vena Cava, Inferior
PubMed: 26075222
DOI: 10.1155/2015/290234 -
Fibrin and Thrombin Sealants in Vascular and Cardiac Surgery: A Systematic Review and Meta-analysis.European Journal of Vascular and... Sep 2020In vascular and cardiac surgery, the ability to maintain haemostasis and seal haemorrhagic tissues is key. Fibrin and thrombin based sealants were introduced as a means... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
In vascular and cardiac surgery, the ability to maintain haemostasis and seal haemorrhagic tissues is key. Fibrin and thrombin based sealants were introduced as a means to prevent or halt bleeding during surgery. Whether fibrin and thrombin sealants affect surgical outcomes is poorly established. A systematic review and meta-analysis was performed to examine the impact of fibrin or thrombin sealants on patient outcomes in vascular and cardiac surgery.
DATA SOURCES
Cochrane CENTRAL, Embase, and MEDLINE, as well as trial registries, conference abstracts, and reference lists of included articles were searched from inception to December 2019.
REVIEW METHODS
Studies comparing the use of fibrin or thrombin sealant with either an active (other haemostatic methods) or standard surgical haemostatic control in vascular and cardiac surgery were searched for. The Cochrane risk of bias tool and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) were used to assess the risk of bias of the included randomised and non-randomised studies; quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two reviewers screened studies, assessed risk of bias, and extracted data independently and in duplicate. Data from included trials were pooled using a random effects model.
RESULTS
Twenty-one studies (n = 7 622 patients) were included: 13 randomised controlled trials (RCTs), five retrospective, and three prospective cohort studies. Meta-analysis of the RCTs showed a statistically significant decrease in the volume of blood lost (mean difference 120.7 mL, in favour of sealant use [95% confidence interval {CI} -150.6 - -90.7; p < .001], moderate quality). Time to haemostasis was also shown to be reduced in patients receiving sealant (mean difference -2.5 minutes [95% CI -4.0 - -1.1; p < .001], low quality). Post-operative blood transfusions, re-operation due to bleeding, and 30 day mortality were not significantly different for either RCTs or observational data.
CONCLUSION
The use of fibrin and thrombin sealants confers a statistically significant but clinically small reduction in blood loss and time to haemostasis; it does not reduce blood transfusion. These Results may support selective rather than routine use of fibrin and thrombin sealants in vascular and cardiac surgery.
Topics: Blood Loss, Surgical; Cardiac Surgical Procedures; Fibrin Tissue Adhesive; Hemostasis; Hemostatics; Humans; Postoperative Hemorrhage; Risk Factors; Thrombin; Time Factors; Tissue Adhesives; Treatment Outcome; Vascular Surgical Procedures
PubMed: 32620348
DOI: 10.1016/j.ejvs.2020.05.016