Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan

Pruthi, Raj S.; Chun, Judy; Richman, Marc

doi:10.1016/s0090-4295(03)00651-4

Cited by 100 publications

(63 citation statements)

References 16 publications

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“…64 Factors that help reduce this include epidural anesthesia, minimally invasive surgery, gentle tissue handling, avoiding of fluid overload 70 and early feeding. 18,71 Furthermore, the use of routine nasogastric decompression should be avoided after surgery as the incidence of fever, atelectasis and pneumoniae are increased in patients with nasogastric tube drainage, and any nasogastric tubes placed during surgery should be removed prior to extubation. 10,72 Chewing gum has previously been used in an attempt to improve the postoperative recovery of bowel function in patients.…”

Section: Prevention Of Prolonged Postoperative Ileusmentioning

confidence: 99%

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Melnyk

Casey

Black

et al. 2013

CUAJ

262

120

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Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

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Section: Prevention Of Prolonged Postoperative Ileusmentioning

confidence: 99%

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Melnyk

Casey

Black

et al. 2013

CUAJ

262

120

View full text Add to dashboard Cite

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“…Using a combination of ketorolac and celecoxib in their fast-track protocol, Pruthi and colleagues were able to reduce the time to bowel movement and discharge to 3 and 5 days, respectively. 3,4 In a recently published protocol, Saar and colleagues utilized oral diclofenac with epidural analgesia to minimize opioid utilization and impacts on bowel motility. 5 With this regimen, postoperative morphine equivalents were significantly reduced and attributed a low rate of gastrointestinal complications (6.4%) to this reduction.…”

Section: Discussionmentioning

confidence: 99%

“…1 A number of institutions have reported fast-track protocols designed to minimize postoperative ileus and shorten the length of stay in these patients. [2][3][4][5][6] A central theme in these protocols has been decreasing perioperative opioid analgesic. This focus has been justified based on the well-established relationship between opioids and bowel dysfunction.…”

Section: Introductionmentioning

confidence: 99%

Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion

Jacobsohn¹,

Davis²,

El-Arabi³

et al. 2015

CUAJ

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Introduction: We instituted a ketamine-predominant analgesic regimen in the peri-and postoperative periods to limit the effects of narcotic analgesia on bowel function in patients undergoing radical cystectomy. The primary end points of interest were time to return of bowel function, time to discharge, and efficacy of the analgesic regimen. Methods: We performed a retrospective chart review of patients undergoing robotic-assisted laparoscopic cystectomy (RARC) with urinary diversion by a single surgeon at our institution from January 1, 2011 to June 30, 2012. Patients receiving the opioid-minimizing ketamine protocol were compared to a cohort of patients undergoing RARC with an opioid-predominant analgesic regimen. Results: In total, 15 patients (Group A) were included in the ketamine-predominant regimen and 25 patients (Group B) in the opioid-predominant control group. Three patients (19%) in Group A discontinued the protocol due to ketamine side effects. The mean time to bowel movement and length of stay in Group A versus Group B was 3 versus 6 days (p < 0.001), and 4 versus 8 days, respectively (p < 0.001). Group A patients received an average of 13.0 mg of morphine versus 97.5 mg in Group B (p < 0.001). Conclusions:Patients who received our ketamine pain control regimen had a shorter time to return of bowel function and length of hospitalization after RARC. Our study has its limitations as a retrospective, single surgeon, single institution study and the nonrandomization of patients. Notwithstanding these limitations, this study was not designed to show inferiority of one approach, but instead to show that our protocol is safe and efficacious, warranting further study in a prospective fashion.

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“…Recently, there have been several prospective randomized trials in the field of general surgery and gynecology supporting the opinion that the benefits outnumber the risks for early NGT removal (2)(3)(4)(5)(6)(7)(8)(9). In the last decade there has also been a trend of early NGT removal after major urologic operations, including radical cystectomy with urinary diversion (10)(11)(12)(13)(14). However, a recently published Cochrane Meta-Analysis of 33 studies concluded that NGT decompression should be abandoned in favor of selective use, since it does not accomplish any of its intended goals (15).…”

Section: Clinical Urology Clinical Urology Doi: 101590/s1677-5538201mentioning

confidence: 99%

“…Their results focused on the importance of metoclopramide with early NGT removal in the reduction of postoperative atelectasis, early return of bowel function, and safety to the small bowel anastomosis (10). In 2003, Pruthi et al with a relatively small sample of patients, was the first to focus on a specific preoperative plan with bowel preparation and patient education, combined with a limited incision length, preperitoneal approach, use of staplers, and early NGT removal, in the early hospital discharge of their patients (12). Inman et al during the same year, with a large sample of 430 patients, retrospectively compared patients who received postoperative NGTs with those who did not, suggesting that NGTs may prolong GI recovery and increase duration of hospitalization (13).…”

Section: Commentsmentioning

confidence: 99%

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion

et al. 2011

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Purpose: Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. Patients and Methods: 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. Results: The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. Conclusions: This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

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Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan

Cited by 100 publications

References 16 publications

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion

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