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Introduction: Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio., Methods: Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics., Results: The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633)., Conclusions: A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery., Methods: ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann-Whitney Fisher's exact T test or Pearson Chi-square test) was used., Results: Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (-€2 356), intensive or intermediate care (-€8 629), medication (-€1 196)), physiotherapy (-€611), laboratory (-€1 625)) and blood transfusion (-€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group., Conclusion: ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery., (© 2021. The Author(s).)

Background and Objectives: Serum albumin perioperative decrease (∆Alb) may reflect the magnitude of the physiological stress induced by surgery. Studies highlighted its value to predict adverse postoperative outcomes, but data in esophageal surgery are scant. This study aimed to investigate the role of ∆Alb to predict major complications after esophagectomy for cancer., Methods: Multicenter retrospective study conducted in five high-volume centers, including consecutive patients undergoing an esophagectomy for cancer between 2006 and 2017. Patients were randomly assigned to a training (n = 696) and a validation (n = 350) cohort. Albumin decrease was calculated on postoperative day 1 and defined as ΔAlb. The primary endpoint was major complications according to Clavien classification., Results: In the training cohort, esophagectomy induced a rapid drop of albumin. Cut-off of ΔAlb was established at 11 g/L and allowed to distinguish patients with adverse outcomes. On multivariable analysis, ΔAlb was identified as an independent predictor of major complications (OR, 1.06; 95% CI, 1.01-1.11; p = .014). Higher BMI and laparoscopy were associated with lower ΔAlb. Analysis of the validation cohort provided consistent findings., Conclusions: ΔAlb appeared as a promising biomarker after oncological esophagectomy, allowing prediction of potential adverse outcomes., (© 2020 Wiley Periodicals LLC.)

Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46-0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12-2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10-2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08-2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32-5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I-V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb-V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake., Competing Interests: The authors declare no conflict of interest.

Objective: To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes., Design: Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS)., Setting: Department of abdominal surgery in a European tertiary centre., Participants: Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded., Results: The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p<0.001). ΔAlb also correlated to overall complications (r=0.485, p<0.001), CCI (r=0.383, p<0.001) and LoS (r=0.468, p<0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and a specificity of 67.2% (AUC: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications., Conclusions: Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Major oncologic surgery is associated with a high incidence of venous thromboembolic events (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE). However, the incidence and risk factors for symptomatic VTE during curative treatment for patients with esophageal cancer are poorly documented., Methods: Data were collected from 30 European centers from 2000 to 2010. The incidence of in-hospital VTE was assessed in 2,944 patients with esophageal cancer having surgery with curative intent, and 50 clinically relevant parameters were assessed as potential risk factors for VTE. Patients received low molecular weight heparin prophylaxis during hospital stay and for 4 weeks after surgery., Results: Eighty-four patients (2.9%) developed a symptomatic VTE; all of them had a DVT and 44 were also diagnosed with a PE. In the VTE group there were 19 postoperative deaths recorded, 5 of which (26.3%) were directly caused by PE at postoperative days 7, 10, 21, 45, and 48 despite VTE prophylaxis. In-hospital postoperative mortality was significantly higher in VTE patients (23% versus 7%, p < 0.001) and mean hospital stay was also longer in this group (33 ± 24 versus 25 ± 21 days, p < 0.001). Multivariable analysis showed that high American Society of Anesthesiologists (ASA) class (p = 0.008), pneumopathy (p = 0.002), or an acute respiratory distress syndrome (ARDS) (p = 0.015) were significantly associated with VTE., Conclusions: Patients with ASA class III or IV and those who present a postoperative pneumopathy or ARDS seem to be at higher risk for VTE. Thus, current VTE screening and thromboprophylaxis for these patients might be inadequate and needs further investigation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: One of the most frequent complications of pancreaticoduodenectomy (PD) is delayed gastric emptying (DGE). The study aim was to evaluate the impact of the type of gastro/duodenojejunal reconstruction (antecolic vs. retrocolic) after PD on DGE incidence., Methods: A systematic review was made according to the PRISMA guidelines. Randomized controlled trials (RCTs) comparing antecolic vs. retrocolic reconstruction were included irrespective of the PD techniques. A meta-analysis was then performed., Results: Six RCTs were included for a total of 588 patients. The overall quality was good. General risk of bias was low. DGE was not statistically significantly different between the antecolic and retrocolic group (OR 0.6, 95% CI 0.31-1.16, p = 0.13). The other main surgery-related complications (pancreatic fistula, hemorrhage, intra-abdominal abscess, bile leak and wound infection) were not dependent on the reconstruction route (OR 0.84, 95% CI 0.41-1.70, p = 0.63). No statistically significant difference in terms of length of hospital stay was found between the 2 groups. There was also no difference of DGE incidence if only pylorus-preserving PD was considered and between the DGE grades A, B or C., Conclusion: This meta-analysis shows that antecolic reconstruction after PD is not superior to retrocolic reconstruction in terms of DGE., (© 2015 S. Karger AG, Basel.)

Background/aims: The aim of the current study was to assess the postoperative evolution of nutritional status and to relate it with postoperative outcomes., Methods: Demographic, surgical and nutritional parameters were assessed 10 days preoperatively (d-10) and 30 days postoperatively (d30) in 146 patients. Risk factors responsible for perioperative (>5% between d-10 and d30) weight loss were identified. Overall, severe (Clavien 3-5) and infectious complications were compared in patients with and without perioperative weight loss (>5%)., Results: Nutritional status worsened beyond the postoperative period as reflected by decreasing weight (67 ± 13 kg at d-10 vs. 63 ± 13 kg at d30, p < 0.001), body mass index (23.4 ± 4 vs. 22.2 ± 4 kg/m2, p < 0.001) and mid upper-arm muscle circumference (MAMC, 241 ± 32 vs. 232 ± 30 mm, p < 0.001). Fifty-two patients (46%) lost >5% of their body weight between d-10 and d30. Patients who presented overall (63 vs. 36%, p = 0.004) and major (27 vs. 10%, p = 0.016) postoperative complications were at significantly higher risk to deteriorate postoperative nutritional status. Multivariate analysis identified low preoperative lean body mass (OR 3.2; 95% CI 1.2-8.9, p = 0.023) and low preoperative MAMC (OR 2.5; 95% CI 0.9-6.8, p = 0.066) as independent risk factors for perioperative weight loss., Conclusions: These data suggest continuing nutritional follow-up after the index hospitalization., (© 2016 S. Karger AG, Basel.)

Objectives: Pancreatic surgery remains associated with important morbidity. Efforts are most commonly concentrated on decreasing postoperative morbidity, but early detection of patients at risk could be another valuable strategy. A simple prognostic score has recently been published. This study aimed to validate this score and discuss possible clinical implications., Methods: From 2000 to 2012, 245 patients underwent a pancreaticoduodenectomy. Complications were graded according to the Dindo-Clavien Classification. The Braga score is based on American Society of Anesthesiologists score, pancreatic texture, Wirsung duct diameter, and blood loss. An overall risk score (0-15) can be calculated for each patient. Score discriminant power was calculated using a receiver operating characteristic curve., Results: Major complications occurred in 31% of patients compared with 17% in Braga's data. Pancreatic texture and blood loss were independently statistically significant for increased morbidity. Areas under the curve were 0.95 and 0.99 for 4-risk categories and for individual scores, respectively., Conclusions: The Braga score discriminates well between minor and major complications. Our validation suggests that it can be used as a prognostic tool for major complications after pancreaticoduodenectomy. The clinical implications, that is, whether postoperative treatment strategies should be adapted according to the patient's individual risk, remain to be elucidated.

Background: Due to the underlying diseases and the need for immunosuppression, patients after lung transplantation are particularly at risk for gastrointestinal (GI) complications that may negatively influence long-term outcome. The present study assessed the incidences and impact of GI complications after lung transplantation and aimed to identify risk factors., Methods: Retrospective analysis of all 227 consecutively performed single- and double-lung transplantations at the University hospitals of Lausanne and Geneva was performed between January 1993 and December 2010. Logistic regressions were used to test the effect of potentially influencing variables on the binary outcomes overall, severe, and surgery-requiring complications, followed by a multiple logistic regression model., Results: Final analysis included 205 patients for the purpose of the present study, and 22 patients were excluded due to re-transplantation, multiorgan transplantation, or incomplete datasets. GI complications were observed in 127 patients (62%). Gastro-esophageal reflux disease was the most commonly observed complication (22.9%), followed by inflammatory or infectious colitis (20.5%) and gastroparesis (10.7%). Major GI complications (Dindo/Clavien III-V) were observed in 83 (40.5%) patients and were fatal in 4 patients (2.0%). Multivariate analysis identified double-lung transplantation (p = 0.012) and early (1993-1998) transplantation period (p = 0.008) as independent risk factors for developing major GI complications. Forty-three (21%) patients required surgery such as colectomy, cholecystectomy, and fundoplication in 6.8, 6.3, and 3.9% of the patients, respectively. Multivariate analysis identified Charlson comorbidity index of ≥3 as an independent risk factor for developing GI complications requiring surgery (p = 0.015)., Conclusion: GI complications after lung transplantation are common. Outcome was rather encouraging in the setting of our transplant center.

Background: The aim of the current study was to assess whether widely used nutritional parameters are correlated with the nutritional risk score (NRS-2002) to identify postoperative morbidity and to evaluate the role of nutritionists in nutritional assessment., Methods: A randomized trial on preoperative nutritional interventions (NCT00512213) provided the study cohort of 152 patients at nutritional risk (NRS-2002 ≥3) with a comprehensive phenotyping including diverse nutritional parameters (n=17), elaborated by nutritional specialists, and potential demographic and surgical (n=5) confounders. Risk factors for overall, severe (Dindo-Clavien 3-5) and infectious complications were identified by univariate analysis; parameters with P<0.20 were then entered in a multiple logistic regression model., Results: Final analysis included 140 patients with complete datasets. Of these, 61 patients (43.6%) were overweight, and 72 patients (51.4%) experienced at least one complication of any degree of severity. Univariate analysis identified a correlation between few (≤3) active co-morbidities (OR=4.94; 95% CI: 1.47-16.56, p=0.01) and overall complications. Patients screened as being malnourished by nutritional specialists presented less overall complications compared to the not malnourished (OR=0.47; 95% CI: 0.22-0.97, p=0.043). Severe postoperative complications occurred more often in patients with low lean body mass (OR=1.06; 95% CI: 1-1.12, p=0.028). Few (≤3) active co-morbidities (OR=8.8; 95% CI: 1.12-68.99, p=0.008) were related with postoperative infections. Patients screened as being malnourished by nutritional specialists presented less infectious complications (OR=0.28; 95% CI: 0.1-0.78), p=0.014) as compared to the not malnourished. Multivariate analysis identified few co-morbidities (OR=6.33; 95% CI: 1.75-22.84, p=0.005), low weight loss (OR=1.08; 95% CI: 1.02-1.14, p=0.006) and low hemoglobin concentration (OR=2.84; 95% CI: 1.22-6.59, p=0.021) as independent risk factors for overall postoperative complications. Compliance with nutritional supplements (OR=0.37; 95% CI: 0.14-0.97, p=0.041) and supplementation of malnourished patients as assessed by nutritional specialists (OR=0.24; 95% CI: 0.08-0.69, p=0.009) were independently associated with decreased infectious complications., Conclusions: Nutritional support based upon NRS-2002 screening might result in overnutrition, with potentially deleterious clinical consequences. We emphasize the importance of detailed assessment of the nutritional status by a dedicated specialist before deciding on early nutritional intervention for patients with an initial NRS-2002 score of ≥3.

Background: Survival after pancreatic head adenocarcinoma surgery is determined by tumor characteristics, resection margins, and adjuvant chemotherapy. Few studies have analyzed the long-term impact of postoperative morbidity. The aim of the present study was to assess the impact of postoperative complications on long-term survival after pancreaticoduodenectomy for cancer., Methods: Of 294 consecutive pancreatectomies performed between January 2000 and July 2011, a total of 101 pancreatic head resections for pancreatic ductal adenocarcinoma were retrospectively analyzed. Postoperative complications were classified on a five-grade validated scale and were correlated with long-term survival. Grade IIIb to IVb complications were defined as severe., Results: Postoperative mortality and morbidity were 5 and 57 %, respectively. Severe postoperative complications occurred in 16 patients (16 %). Median overall survival was 1.4 years. Significant prognostic factors of survival were the N-stage of the tumor (median survival 3.4 years for N0 vs. 1.3 years for N1, p = 0.018) and R status of the resection (median survival 1.6 years for R0 vs. 1.2 years for R1, p = 0.038). Median survival after severe postoperative complications was decreased from 1.9 to 1.2 years (p = 0.06). Median survival for N0 or N1 tumor or after R0 resection was not influenced by the occurrence and severity of complications, but patients with a R1 resection and severe complications showed a worsened median survival of 0.6 vs. 2.0 years without severe complications (p = 0.0005)., Conclusions: Postoperative severe morbidity per se had no impact on long-term survival except in patients with R1 tumor resection. These results suggest that severe complications after R1 resection predict poor outcome.

Purpose: Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis., Method: This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay., Results: Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5 days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3 days, p < 0.0001)., Conclusion: No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandoned.

Background & Aims: Malnutrition is a recognized risk factor for perioperative morbidity, but there is currently no standardized definition of malnutrition. The Nutrition Risk Screening 2002 score was recently proposed to identify patients at nutritional risk who may benefit from nutritional support therapy, and has been officially adopted by the European Society of Parenteral and Enteral Nutrition. The aim of this study was to assess the value of the Nutrition Risk Screening 2002 score in predicting the incidence and severity of postoperative complications in gastrointestinal surgery., Methods: We prospectively evaluated 608 patients admitted for elective gastrointestinal surgery. Nutritional risk was defined by the Nutrition Risk Screening 2002 score and correlated to the incidence and severity of postoperative complications. Complications were classified using an established surgical complication classification., Results: The overall incidence of nutritional risk was 14%. We observed a significantly higher complication rate of 40% (35 out of 87) in patients at nutritional risk, compared to 15% (81 out of 521) in patients with a normal score (p<0.001). The incidence of severe complications was significantly higher in patients at nutritional risk (54% versus 15%; p<0.001). The odds ratio to develop a complication was 2.8 in patients at risk (p=0.001), and 3.0 in patients with malignant disease (p<0.001). The median length of stay in nutritional risk patients was significantly longer (10 versus 4 days, p<0.001)., Conclusion: The prevalence of nutritional risk patients in gastrointestinal surgery is high. We showed that nutritional risk screening using the NRS 2002 strongly predicts the incidence and severity of complications.

Postoperative enteral nutrition is a widely accepted route of application for nutrition formulas due to a low complication rate, a good acceptance by patients. and a favorable cost-effectiveness. We report three cases of bezoar ileus after early postoperative enteral nutrition, using a fine needle jejunostomy (FNJ) in two cases and a nasoduodenal tube in one case. A male patient who underwent gastric resection for a gastrointestinal stroma tumor and was nourished through an fine needle jejunostomy developed an acute abdomen on the seventh postoperative day. Surgical exploration revealed a mechanical ileus caused by denaturated nutrition formula distal to the catheter tip. The second case, a female patient, underwent gastric resection for a gastric cancer and on the fourth postoperative day developed acute onset of abdominal pain. Intraoperative findings were the same as described in the first case. The third case, a male patient with necrotizing cholecystitis, underwent open cholecystectomy. Postoperative enteral feeding was performed using a nasoduodenal tube. He developed a small bowel obstruction on the 17th postoperative day that was caused by an intraluminal bezoar. In conclusion, bezoar formation represents an underestimated complication of postoperative enteral feeding. Acute onset of abdominal pain and the development of small bowel obstruction are the main clinical symptoms of this severe complication. The pathogenesis of bezoar formation remains unclear.