Enhanced recovery pathways in pancreatic surgery: State of the art

Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial i n t e r m s o f i m p rove d p o s t o p e ra t i ve o u t c o m e s, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways.

Acupuncture accelerates recovery after general anesthesia: a prospective randomized controlled trial

BACKGROUND： Acupuncture anesthesia was created in the 1950＇s in China and continues to be used there today during most major surgeries. It is widely used in China for such complex operations as brain heart, and abdominal surgery. It is popular in China because it is economical, practical, and beneficial to the patients. With acupuncture anesthesia there is less bleeding during surgery and there is also quicker post-operative recovery. OBJECTIVE： This randomized prospective study aims at comparing the effect of two acupoints （Yongquan, KI1 and Renzhong, DU26） with sham acupuncture and no acupuncture on the time to recovery of consciousness after general anesthesia by means of the Bispectral Index monitor （BIS） DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS： This is a prospective randomized controlled study. We randomly assigned 50 patients to 5 groups during recovery from surgical anesthesia. Four groups had acupuncture on KI1 （group A）, DU26 （groups B）, both KI1 and DU26 （group C）, and sham points （group D）, and one had no acupuncture （group E）. MAIN OUTCOME MEASURES： Bispectral Index （BIS）, time to spontaneous eye opening, time to tracheal extubation, and time to following commands were measured as the main outcome measures RESULTS： Time to spontaneous eye opening differed among groups （P=0.002）, as well as time to tracheal extubation （P〈0.000 1） and time to following commands （P=0.000 6）. BIS values differed significantly among groups both 5 and 10 min after the end of anesthesia （P〈0.000 1 and P=0.000 4, respectively）. BIS values of groups D and E were lower than those of the other groups and those of group C were higher. The same pattern was observed also 15 and 30 rain after the end of anesthesia although the difference among groups was not significant at these time points （P=0.164 and P=0.104 respectively）. CONCLUSION： Acupuncture on DU26 and KI 1 accelerates recovery of consciousness after general anesthesia. Moreover, a possible synergistic effect of DU26 and KI1 is suggested. This issue may play a role in the optimization of operating room management and raise interest about the usefulness of acupuncture on unconsciousness states of different nature.

Liver resection for hepatocellular carcinoma within a fast-track management: a propensity-score matched analysis between open and laparoscopic approach

Aim:The study was designed to assess the implications of enhanced recovery after surgery(ERAS)approach in patients submitted to open liver resection for hepatocellular carcinoma(HCC)comparing their short term outcome with patients treated by laparoscopic approach,in a case-matched design.Methods:The open-group(n=60)was matched in a ratio of 1:1 with patients undergoing laparoscopic liver resection for HCC(Lap-group,n=60),with a matching achieved on a basis of propensity scores including 6 covariates representing patients characteristics and severity of the disease.Primary outcome analysis was performed in terms of ERAS-specific items and postoperative morbidity and mortality.Results:Overall morbidity and mortality were comparable between groups.Incidence of ascites was slightly higher in the open-compared with the Lap-group(respectively 11.7%and 13.3%),without statistical significance.The need for introduction or increase of chronic diuretic therapy was significantly higher in the open-compared with the Lap-group(16.7%vs.11.7%,P=0.046).Furthermore,ascites more frequently required percutaneous drainage in the open-compared with the Lap-group(5%vs.1.7%respectively,P=0.041).Conclusion:In patients who can’t benefit from minimally-invasive approach because of disease characteristics,ERAS management seems to be associated with an improved postoperative functional recovery and postoperative outcomes,comparable to those of the minimally invasive approach.