Enhanced Recovery After Surgery (ERAS) programs follow a multimodal, multidisciplinary perioperative care approach that combines evidence-based perioperative strategies to accelerate the functional recovery process and improve surgical outcomes. Despite increasing evidence that supports the use of ERAS programs in gastrointestinal and pelvic surgery, data regarding the development of ERAS programs in spine surgery are scarce. To evaluate the impact of an Enhanced Recovery After Spine Surgery (ERSS) program in a US academic cancer center, the authors introduced such a program and hypothesized that ERSS would have a significant influence on meaningful clinical measures of postoperative recovery, such as pain management, postoperative length of stay (LOS), and complications.
A multimodal, multidisciplinary, continuously evolving team approach was used to develop an ERAS program for all patients undergoing spine surgery for metastatic tumors at The University of Texas MD Anderson Cancer Center from April 2015 through September 2016. This study describes the introduction of that ERSS program and compares 41 patients who participated in ERSS with a retrospective cohort of 56 patients who underwent surgery before implementation of the program. The primary objectives were to assess the effect of an ERSS program on immediate postoperative pain scores and in-hospital opioid consumption. The secondary objectives included assessing the effect of ERSS on postoperative in-hospital LOS, 30-day readmission rates, and 30-day postoperative complications.
The ERSS group showed a trend toward better pain scores and decreased opioid consumption compared with the pre-ERSS group. There were no significant differences in LOS, 30-day readmission rate, or 30-day complication rate observed between the two groups.
An ERSS program is feasible and potentially effective on perioperative pain control and opioid consumption, and can expedite recovery in oncological spine surgery patients. Larger-scale research on well-defined postoperative recovery outcomes is needed.
Measuring patient-reported outcomes (PROs) has become increasingly important for assessing quality of care and guiding patient management. However, PROs have yet to be integrated with traditional clinical outcomes (such as length of hospital stay) to evaluate perioperative care. This study aimed to utilize longitudinal PRO assessments to define the postoperative symptom-recovery trajectory in patients undergoing thoracic surgery for lung cancer.
Newly diagnosed patients (N=60) with stage I or II non-small cell lung cancer who underwent either standard open thoracotomy or video-assisted thoracoscopic surgery (VATS) lobectomy reported multiple symptoms from presurgery to 3 months postsurgery using the MD Anderson Symptom Inventory (MDASI). We conducted Kaplan–Meier analyses to determine when symptoms returned to presurgical levels and to mild severity levels during recovery.
The most-severe postoperative symptoms were fatigue, pain, shortness of breath, disturbed sleep, and drowsiness. The median time to return to mild symptom severity for these 5 symptoms was shorter than return to baseline severity, with fatigue taking longer. Pain recovered more quickly for patients who underwent VATS lobectomy vs standard open thoracotomy (8 days vs 18 days, respectively; P = .022). Patients who had poor preoperative performance status or comorbidities reported higher postoperative pain (all P < .05).
Assessing symptoms from the patient's perspective throughout the postoperative recovery period is an effective strategy for evaluating perioperative care. This study demonstrates that the MDASI is a sensitive tool for detecting symptomatic recovery with an expected relationship among surgery type, preoperative performance status, and comorbid conditions.
The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization and complications.
Summary of Background Data
Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial.
Using a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N=106) or IV-PCA (N=34). Patient-reported pain was measured on a Likert scale (0–10) at standard time intervals. Cumulative pain area under the curve (AUC) was determined using the trapezoidal method.
Between the study groups key demographic, comorbidity, clinical and operative variables were equivalently distributed. The median AUC of the postoperative time 0 to 48 hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, p=0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 66%, p=0.05). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia related events requiring change in analgesic therapy were comparable (12.2% vs. 2.9%, respectively, p=0.187). Grade ≥3 surgical complications, median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the OR (0.9 vs 3.1%) were similar (all p>0.05). There were no mortalities in either group.
In major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.
Few empirical studies have combined the patient’s perspective (patient-reported outcomes, or PROs) with clinical outcomes (risk for complications, length of hospital stay, return to planned treatment) to assess the effectiveness of treatment after thoracic surgery for early-stage non-small cell lung cancer (NSCLC).
Quantitatively measure PROs to assess functional recovery postsurgery.
Treatment-naïve patients (N=72) with NSCLC who underwent either open thoracotomy or video-assisted thoracoscopic surgery (VATS) used the MD Anderson Symptom Inventory (MDASI) to report symptom interference with general activity, work, walking, mood, relations with others, and enjoyment of life for 3 months postsurgery. Functional recovery was defined as interference scores returning to presurgery levels. The MDASI’s sensitivity to change in functional recovery over time was evaluated via its ability to distinguish between surgical techniques.
Interference scores increased sharply by day 3 postsurgery (all P<0.001), then returned to baseline levels via different trajectories. Patients who had unscheduled clinic visits during the study period reported higher scores on all 6 MDASI interference items (all P<0.05). Compared with the open-thoracotomy group, the VATS group returned more quickly to baseline interference levels for walking (18 vs 43 days), mood (8 vs 19 days), relations with others (4 vs 16 days) and enjoyment of life (15 vs 41 days) (all P<0.05).
Repeated measurement of MDASI interference characterized functional recovery after thoracic surgery for NSCLC and was sensitive to VATS’ ability to enhance postoperative recovery. Further study of the clinical applicability of measuring recovery outcomes using PRO-based functional assessment is warranted.
scite is a Brooklyn-based startup that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.