Background Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it have not been widely utilized in spinal surgery. This study is to evaluate the implementation of an ERAS pathway for patients undergoing oblique lumbar interbody fusion (OLIF) surgery. Methods This was a retrospective cohort study of patient who underwent OLIF in 2018 prior to ERAS ("pre-ERAS" ,n=23) and in 2019 after ERAS was instituted ("ERAS", n=24). Major outcomes were collected included demographics, length of hospital stay, nancial cost, postoperative complications, off-bed time and perioperative factors. Visual Analogue Scale (VAS) was used to evaluate the pain. The ERAS pathway and compliance with pathway elements were also recorded. Results After ERAS implementation, we found no signi cant differences in the baseline characteristics between the two groups. In our study, the mean stay in the hospital was signi cantly lower (p= 0.033) in the ERAS group (15.3±3.9 days) compared to the standard pathway group (13.0±3.1 days). In comparison to the standard group, we also found a variation between the nancial costs of surgery and hospitalization [(16446.5±4353.3)vs(14237.7±2784.9) USD, P < 0.05]. The ERAS group manifested a lower blood loss compared with the pre-ERAS group with statistical signi cance [(68.3±57.1)vs(119.3±104.8) ml, P < 0.05]. There was no signi cant difference in operative time, complications, and 30-d readmission rates (P > 0.05). Pain scores between the two groups showed a signi cant difference during the 3th hour and 6th hour (P < 0.05). Conclusion Institution of an ERAS protocol appears to accelerate functional recovery and reduce length of stay, nancial costs and decreased pain.

BackgroundThe perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients.MethodsWe performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS.ResultsOnly patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20–101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11–235) vs. 50 ivMEQ (7–277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14–2.45; p = 0.009) and CSS (HR = 1.53, 1.04–2.25; p = 0.030) on multivariable analyses.ConclusionsEpidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

Background: Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery.Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. Methods: A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). Results: The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups.Conclusions: Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.

This is the first study to investigate the effects of adding anesthesia ERAS components to an existing surgical ERAS protocol for radical cystectomy. We found that with the addition of anesthesia-related interventions, there was a decrease in transfusions and nausea.

Purpose: To our knowledge the reliability of administrative claims codes to report postoperative radical cystectomy complications has not been examined. We compared complications identified by claims data to those abstracted from clinical chart review following radical cystectomy. Methods:We manually reviewed the charts of 268 patients treated with radical cystectomy between 2014 and 2016 for 30-day complications and queried administrative complication coding using 805 ICD-9/10 codes. Complications were categorized. Using Cohen κ statistics we assessed agreement between the 2 methods of complication reporting for 1 or more postoperative complications overall, categorical complications and complications stratified by the top quartile length of hospital stay and patients who were readmitted. Results:At least 1 or more complications were recorded in 122 patients (45.5%) through manual chart review and 80 (29.9%) were recorded via claim coding data with a concordance rate of κ = 0.16, indicating weak agreement. Concordance was generally weak for categorical complication rates (range 0.05 to 0.36). However, when examining only the top length of stay quartile, 1 or more complications were reported in 32 patients (65%) by the manual chart review and in 12 (25%) via coding data with a concordance rate of κ = −0.2. Agreement was weak, similar to the total cohort. Conclusions:Manual chart review and claim code identification of complications are not highly concordant even when stratified by patients with an extended length of stay, who are known to have more frequent complications. Researchers and administrators should be aware of these differences and exercise caution when interpreting complication reports.

The field of medical oncology is experiencing a period of rapid evolution owing to advances in the fields of genomics, tumor biology, and immunology. These disciplines have provided valuable insights into the heterogeneity between breast tumors, key oncogenic drivers, and the role of the immune system in the natural history of breast cancer. This knowledge is translating into many novel therapeutic strategies using personalized medicines, targeted drug delivery systems, and immunomodulatory agents in the treatment of both the early and metastatic stages of the disease. This review article attempts to cover the major developments in experimental therapeutics and how they relate to our understanding of breast cancer and its various biologic subtypes.

independent observer. We then utilized TDABC as previously described to calculate the cost of each phase of care of the clinic visit.RESULTS: Granular process flow maps were created for each of the 304 patients seen in our urologic oncology clinic (including 110 prostate cancer, 44 bladder cancer, and 32 renal cell carcinoma visits). External validation of 10 randomly selected patients confirmed beacon room accuracy within 30 seconds. Figure 1 details the median time of each phase of care for our renal cell carcinoma patients (Figure 1). Utilizing TDABC, the average cost per renal cell visit was $86 and median wait time 30 minutes.CONCLUSIONS: BLE tracking systems are frequently advertised to be less than 1/5 the cost of legacy tracking solutions. With the proper configuration and analytics, we believe this approach has the potential to nearly fully automate operations flow mapping and allows for accurate direct labor costs in health care. We demonstrate this system can be successfully implemented in urology, and we next seek to develop strategies that mitigate inefficiency and minimize cost.