scholarly journals P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Ana Maria Saenz Macias ◽  
Adam Frampton
Keyword(s):  
Enhanced Recovery ◽  
Surgical Care ◽  
International Study ◽  
Optimal Level ◽  
Normal Serum ◽  
Amylase Level ◽  
Post Surgery ◽  
Whipple’S Procedure ◽  
Pancreatic Fistulas ◽  
Drain Amylase

Abstract Background Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure. Methods Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021. Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L). Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care. Results A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone. Conclusions Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.

scholarly journals Realistic Advantages of Early Surgical Drain Removal after Pancreatoduodenectomy: A Single-Institution Retrospective Study

2021 ◽  
Vol 10 (12) ◽  
pp. 2716
Author(s):  
So-Jeong Yoon ◽  
So-Kyung Yoon ◽  
Ji-Hye Jung ◽  
In-Woong Han ◽  
Dong-Wook Choi ◽  
...  
Keyword(s):  
Enhanced Recovery ◽  
Single Institution ◽  
Early Removal ◽  
Drain Removal ◽  
Early Return ◽  
Drain Fluid ◽  
Pancreatic Fistulas ◽  
Hospital Stays ◽  
Removal Group ◽  
Surgical Drain

The latest guidelines from the Enhanced Recovery After Surgery (ERAS®) Society stated that early drain removal after pancreatoduodenectomy (PD) is beneficial in decreasing complications including postoperative pancreatic fistulas (POPFs). This study aimed to ascertain the actual benefits of early drain removal after PD. The data of 450 patients who underwent PD between 2018 and 2020 were retrospectively reviewed. The surgical outcomes were compared between patients whose drains were removed within 3 postoperative days (early removal group) and after 5 days (late removal group). Logistic regression analysis was performed to identify the risk factors for clinically relevant POPFs (CR-POPFs). Among the patients with drain fluid amylase < 5000 IU on the first postoperative day, the early removal group had fewer complications and shorter hospital stays than the late removal group (30.9% vs. 54.5%, p < 0.001; 9.8 vs. 12.5 days, p = 0.030, respectively). The incidences of specific complications including CR-POPFs were comparable between the two groups. Risk factor analysis showed that early drain removal did not increase CR-POPFs (p = 0.163). Although early drain removal has not been identified as apparently beneficial, this study showed that it may contribute to an early return to normal life without increasing complications.

Auricular field nerve stimulation using the NSS-2 BRIDGE® device as an alternative to opioids following kidney donor surgery

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Jacques E. Chelly ◽  
Amy L. Monroe ◽  
Raymond M. Planinsic ◽  
Amit Tevar ◽  
Brittany E. Norton
Keyword(s):  
Enhanced Recovery ◽  
Randomized Study ◽  
Cranial Nerves ◽  
Oral Morphine ◽  
Oral Intake ◽  
Control Group ◽  
Hospital Data ◽  
Kidney Donor ◽  
Post Surgery ◽  
Post Operative Nausea

Abstract Objectives The purpose of this study was to investigate the role that the NSS-2 BRIDGE® device, an auricular field nerve stimulator, may play in reducing opioid requirement and pain in kidney donor surgery. It was not a randomized study. Electrophysiologic studies have demonstrated that the stimulation of the cranial nerves produced by the NSS-2 BRIDGE® device modulates the ascending/descending spinal pain pathways, especially at the level of the limbic system. Methods The design compared the effects of the NSS-2 BRIDGE® device (NSS 2-BRIDGE® device group; n=10) to a control group (n=10). In both groups, the surgery was performed using the same standard enhanced recovery after surgery protocol based on the use of a multimodal analgesic approach. For the active treatment group, the NSS-2 BRIDGE® device was placed in the post anesthesia care unit. The primary endpoint was opioid requirement (oral morphine equivalent, OME in mg) at 24 h post-surgery. Secondary endpoints included pain (0–10), at 24 and 48 h, time to discharge from the recovery room, incidence of post-operative nausea and vomiting at 24 h, time to oral intake, time to ambulation, and time to discharge from the hospital. Data was analyzed using unpaired t-test and presented as mean ± standard deviation. Results Compared to control, the use of the NSS-2 BRIDGE® was associated with a 75.4% reduction in OME (33.6 vs. 8.3 mg; p=0.03) and 41.5% reduction in pain (5 vs. 3.28; p=0.06) at 24 h and a 73.3% difference in pain at 48 h (1.6 ± 1.6 vs. 6.0 ± 2.8; p=0.0004). There was no difference in non-opioid analgesics administration between groups. Conclusions The tolerability of NSS-2 BRIDGE® device was reported by most to be excellent. This study suggests that the NSS-2 BRIDGE® device may represent a complementary approach for controlling postoperative opioid consumption and pain in patients undergoing kidney donation.

Decision analysis supports the use of drain amylase-based enhanced recovery method after esophagectomy

2018 ◽  
Vol 31 (10) ◽  
Author(s):  
B Jiang ◽  
V P Ho ◽  
J Ginsberg ◽  
S J Fu ◽  
Y Perry ◽  
...  
Keyword(s):  
Decision Analysis ◽  
Enhanced Recovery ◽  
Recovery Method ◽  
Drain Amylase

scholarly journals Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

2018 ◽  
Vol 9 ◽  
pp. 215145851875445 ◽  
Author(s):  
Christopher P. Childers ◽  
Anaar E. Siletz ◽  
Emily S. Singer ◽  
Claire Faltermeier ◽  
Q. Lina Hu ◽  
...  
Keyword(s):  
Total Joint Replacement ◽  
Enhanced Recovery ◽  
Surgical Care ◽  
Healthcare Research ◽  
Continuous Passive Motion ◽  
Safety Program ◽  
Vte Prophylaxis ◽  
Surgical Technical ◽  
National Implementation ◽  
Evidence Review

Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

scholarly journals Secrets, puzzles and mysteries of macroamylasemia

2020 ◽  
Vol 46 (1) ◽  
pp. 12-22
Author(s):  
N. B. Gubergrits ◽  
N. V. Byelyayeva ◽  
G. M. Lukashevich ◽  
T. L. Mozhyna
Keyword(s):  
Serum Amylase ◽  
Amylase Activity ◽  
Clinical Manifestations ◽  
Specific Treatment ◽  
Normal Serum ◽  
Amylase Level ◽  
Clearance Ratio ◽  
Urine Amylase ◽  
Classical Constant

Physiological features of amylase synthesis and excretion are considered in the article, presence of other sources of amylase synthesis different from pancreas and salivary glands is emphasized. Definitions of hyperenzymemia and macroamylasemia (MAE) are given. MAE is a state characterized by presence of circulating complexes of normal serum amylase with protein or carbohydrates in blood. There are 3 types of MAE: first — classical (constant hyperamylasemia, decreased amylase level in urine, high blood concentration of macroamylase complexes); second — hyperamylasemia with slightly decreased amylase activity in urine, macroamylase/normal amylase ratio is less than in the first type; third — normal blood and urine amylase activity, low macroamylase/normal amylase ratio. Pathogenesis is explained by connection of blood amylase and acute phase protein in different inflammatory, infectious diseases, malabsorption. MAE clinical manifestations could be absent, sometimes abdominal pain is possible. Hyperamylasemia and reduced urine amylase activity are typical. MAE diagnostics means determination of macroamylase complexes in blood (chromatography, calculation of the clearance ratio of amylase and creatinine). The article presents clinical cases describing extra-pancreatic MAE in women with malignant ovarian lesions. The question of expediency of thorough diagnostic examination in asymptomatic MAE is raised, which may turn out to be a symptom of cancer. The lack of specific treatment for MAE is emphasized.

Implementation science approaches to enhance uptake of complex interventions in surgical settings

2020 ◽  
Vol 44 (2) ◽  
pp. 310
Author(s):  
Angela Byrnes ◽  
Alison Mudge ◽  
David Clark
Keyword(s):  
Implementation Science ◽  
Enhanced Recovery ◽  
Interdisciplinary Collaboration ◽  
Complex Interventions ◽  
Surgical Care ◽  
Practice Change ◽  
Change Initiatives ◽  
Course Of Action ◽  
Surgical Setting

Achieving practice change in the complex healthcare environment is difficult. Effective surgical care requires coordination of services across the continuum of care, involving interdisciplinary collaboration across multiple units, with systems and processes that may not connect effectively. Principles of enhanced recovery after surgery (ERAS) are increasingly being incorporated into facility policies and practice, but the literature reports challenges with both initial adherence and mid- to long-term sustainability. Greatest adherence is typically observed for the intraoperative elements, which are within the control of a single discipline, with poorest adherence reported for postoperative processes occurring in the complex ward environment. Using ERAS as an example, this perspective piece describes the challenges associated with implementation of complex interventions in the surgical setting, highlighting the value that implementation science approaches can bring to practice change initiatives and providing recommendations as to suggested course of action for effective implementation.

Outcomes After Bowel Resection for Inflammatory Bowel Disease in the Era of Surgical Care Bundles and Enhanced Recovery

2019 ◽  
Vol 24 (1) ◽  
pp. 123-131 ◽  
Author(s):  
Anthony P. D’Andrea ◽  
Prerna Khetan ◽  
Reba Miller ◽  
Patricia Sylla ◽  
Celia M. Divino
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Bowel Resection ◽  
Enhanced Recovery ◽  
Surgical Care ◽  
Care Bundles ◽  
Inflammatory Bowel

Post-surgery, post-anaesthesia complications

2017 ◽  
Author(s):  
Andrew Toner ◽  
Mark Hamilton ◽  
Maurizio Cecconi
Keyword(s):  
High Risk ◽  
Postoperative Complications ◽  
Inflammatory Responses ◽  
Enhanced Recovery ◽  
Clinical Intervention ◽  
Evidence Base ◽  
Thromboembolism Prophylaxis ◽  
Surgical Safety ◽  
Post Surgery ◽  
Recovery Protocols

Postoperative complications are common in high-risk surgical populations and are associated with poor short-term and long-term outcomes. Morbidity can be identified using prospective assessment of pathological criteria, or deviations from the ideal postoperative course requiring clinical intervention. While infections are the most prevalent complication type, morbidity affecting the heart, lungs, kidneys, or brain carry the worst prognosis. Specific pathophysiological processes drive morbidity in each organ system. In addition, dysfunction of the cardiovascular and immune systems can lead to multiorgan impairment, and have been the focus of many clinical trials. Perioperative strategies backed by the strongest evidence base include smoking cessation, surgical safety checklists, perioperative warming, pre-emptive antibiotics, venous thromboembolism prophylaxis, enhanced recovery protocols, and early critical care rescue when complications arise. Isolated attempts to optimize cardiovascular function or attenuate inflammatory responses have not been consistently successful in improving outcomes. As the proportion of surgical patients meeting high-risk criteria rises, reducing the incidence of postoperative complications has become a priority in many developed healthcare systems. To meet this need, improved implementation of proven strategies should be combined with routine and rigorous surgical outcome reporting. In addition, advances in pathophysiological understanding may lead to novel interventions offering multisystem protection in the surgical period.

A Simple Algorithm for Drain Management after Pancreaticoduodenectomy

2012 ◽  
Vol 78 (10) ◽  
pp. 1143-1146 ◽  
Author(s):  
Nicholas N. Nissen ◽  
Vijay G. Menon ◽  
Vichin Puri ◽  
Alagappan Annamalai ◽  
Brendan Boland
Keyword(s):  
Pancreatic Fistula ◽  
Temporal Pattern ◽  
Management Strategy ◽  
Simple Algorithm ◽  
International Study ◽  
Study Group ◽  
International Study Group ◽  
Drain Removal ◽  
Drain Amylase ◽  
Drain Management

Pancreatic fistula (PF) continues to be the Achilles’ heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD) 0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. Of these 76 patients, eight patients (11%) developed Grade A, B, or C PF by International Study Group of Pancreatic Fistula criteria. POD 1 DA levels correlated closely with PF rates when high (greater than 5000 U/L, 100% PF rate) and low (less than 100 U/L, 2% PF rate). In patients with intermediate POD 1 DA (100 to 5000 U/L), 42 and 74 per cent had low DA levels on POD 3 and 5, respectively, and the PF rate was four of 31 (13%). Overall, the temporal pattern of decreasing DA levels after PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have occurred on a mean of 1.8 days and median 1 day after surgery.

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