67 results on '"Gabriel E. Mena"'
Search Results
2. Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery
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Jolyn S. Taylor, Maria D. Iniesta, Andres Zorrilla-Vaca, Katherine E. Cain, Javier D. Lasala, Gabriel E. Mena, Larissa A. Meyer, and Pedro T. Ramirez
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Obstetrics and Gynecology - Published
- 2023
3. Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery
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Maria Garcia-Nebreda, Andrés Zorrilla-Vaca, Javier Ripollés-Melchor, Ane Abad-Motos, Edurne Alvaro Cifuentes, Alfredo Abad-Gurumeta, Gabriel E. Mena, Michael C. Grant, and Gloria Paseiro-Crespo
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Postoperative Complications ,Stomach Neoplasms ,Humans ,Surgery ,Adenocarcinoma ,Length of Stay ,Enhanced Recovery After Surgery ,Digestive System Surgical Procedures - Abstract
Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT).This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes.Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p 0.01).Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.
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- 2022
4. Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis
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Reza J. Mehran, David C. Rice, Ta Charra Woodward, Brittany Kruse, Girish P. Joshi, Wendell H. Williams, Javier Lasala, Carla M Patel, Gabriel E. Mena, Andres Zorrilla-Vaca, and Ara A. Vaporciyan
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medicine.medical_specialty ,Ileus ,Postoperative pain ,Pacu ,medicine ,Humans ,Ketamine ,Dexmedetomidine ,Propensity Score ,Retrospective Studies ,Pain, Postoperative ,biology ,business.industry ,Thoracic Surgery ,medicine.disease ,biology.organism_classification ,Analgesics, Opioid ,Anesthesiology and Pain Medicine ,Cardiothoracic surgery ,Anesthesia ,Concomitant ,Propensity score matching ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
OBJECTIVES To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P
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- 2022
5. Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway
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Juan P. Cata, Katherine E. Cain, Micah Vaughn, Gabriel E. Mena, Andres Zorrilla-Vaca, Pedro T. Ramirez, Larissa A. Meyer, Sarah P. Huepenbecker, Maria D. Iniesta, and Javier Lasala
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medicine.medical_specialty ,urologic and male genital diseases ,Article ,Gynecologic Surgical Procedures ,Postoperative Complications ,medicine ,Humans ,Rifle ,Enhanced recovery after surgery ,Aged ,business.industry ,Incidence ,Incidence (epidemiology) ,Acute kidney injury ,Obstetrics and Gynecology ,Perioperative ,Acute Kidney Injury ,Middle Aged ,medicine.disease ,female genital diseases and pregnancy complications ,Surgery ,Blood pressure ,Oncology ,Cohort ,Propensity score matching ,Female ,Enhanced Recovery After Surgery ,business - Abstract
OBJECTIVE: To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS: We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher’s Exact, and Wilcoxon rank-sum tests were used. RESULTS: Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p=.004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p5 minutes (41.7% vs 30.7%, p
- Published
- 2021
6. The quantra hemostasis analyzer compared to thromboelastography (TEG) in the surgical oncologic population: A prospective observational trial
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Timothy A. Jackson, Allen A. Holmes, Olakunle Idowu, Jagtar Singh Heir, Ifey Ifeanyi-Pillette, Piotr Kwater, Javier Lasala, Gabriel E. Mena, and Pascal Owusu-Agyemang
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Adult ,Male ,medicine.medical_specialty ,Non-Randomized Controlled Trials as Topic ,Observational Trial ,Population ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Neoplasms ,Coagulopathy ,medicine ,Humans ,Prospective Studies ,education ,Aged ,Aged, 80 and over ,education.field_of_study ,medicine.diagnostic_test ,Hemostatic Techniques ,business.industry ,General Medicine ,Perioperative ,Blood Coagulation Disorders ,Middle Aged ,Prognosis ,medicine.disease ,Point of care device ,Thromboelastography ,Thrombelastography ,Oncology ,Surgical Procedures, Operative ,030220 oncology & carcinogenesis ,Hemostasis ,Female ,030211 gastroenterology & hepatology ,Surgery ,Observational study ,Radiology ,business ,Follow-Up Studies - Abstract
BACKGROUND Management of coagulopathy during major oncologic surgery can be multifactorial and challenging. Viscoelastic assays (VEAs) can be useful in providing vital data about the mechanism of coagulopathy in these dynamic circumstances. OBJECTIVES A prospective nonrandomized observational study with the aim of describing the coagulation parameters of patients undergoing major oncologic surgery using the Quantra® and TEG® 5000 systems. Our secondary objectives included the correlation between Quantra and TEG parameters, and the times to result for both technologies. METHODS This study included 74 adults undergoing oncologic surgery with an anticipated blood loss of more than 500 ml. For each subject, whole blood samples for each device were collected at multiple points perioperatively for comparison. RESULTS Correlation coefficients between Quantra and TEG parameters were 0.8 and above, indicating a very strong correlation (p
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- 2021
7. Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis
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Christopher L. Wu, Pedro T. Ramirez, Bradley H. Lee, Andres Zorrilla-Vaca, Gabriel E. Mena, and Alexandra Sideris
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medicine.medical_specialty ,business.industry ,Subgroup analysis ,Odds ratio ,Perioperative ,Cochrane Library ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,Opioid ,Randomized controlled trial ,030202 anesthesiology ,law ,Internal medicine ,Meta-analysis ,Medicine ,Elective surgery ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills. Methods The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months. Results In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%). Conclusions Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.
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- 2021
8. Enhanced recovery after surgery improves postdischarge recovery after pulmonary lobectomy
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David B. Nelson, Reza J. Mehran, Gabriel E. Mena, Wayne L. Hofstetter, Ara A. Vaporciyan, Mara B. Antonoff, and David C. Rice
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Pulmonary and Respiratory Medicine ,Surgery ,Cardiology and Cardiovascular Medicine - Abstract
Enhanced recovery after surgery protocols are known to accelerate immediate postoperative recovery and to facilitate healing. Our purpose was to further characterize benefits after discharge from the hospital.An institutional database was queried to identify patients with clinical stage I non-small cell lung cancer who were classified as Eastern Cooperative Oncology Group performance status 0 and received a lobectomy between January 1, 2000, and August 31, 2020. The presence or absence of symptoms (ie, pain, shortness of breath, fatigue, among others) and performance status were recorded by clinic staff at the time of follow-up. Cox proportional hazards regression was used to identify factors associated with postdischarge recovery, which was defined as a return to Eastern Cooperative Oncology Group performance status 0 in the follow-up clinic.A total of 935 patients were identified (pre-enhanced recovery after surgery, 523; transition period, 222; enhanced recovery after surgery, 190). Outpatient performance status data were recorded in 774 of 935 patients (83%). The number of patients reporting symptoms at the 1-month follow-up appointment decreased from the pre-enhanced recovery after surgery to transition to the enhanced recovery after surgery period (60%, 50%, and 33%, respectively, P .001), predominately due to less pain reported (43%, 35%, and 23%, respectively, P = .001). At 6-month follow-up, these differences were no longer statistically significant. Surgery during the enhanced recovery after surgery period was independently associated with significant improvements in postdischarge recovery (hazard ratio, 1.60, 95% confidence interval, 1.29-2.00), and the presence of coronary artery disease (hazard ratio, 0.69, P = .006) and receipt of thoracotomy (hazard ratio, 0.84, P = .036) were independently associated with delayed postdischarge recovery.Enhanced recovery is associated with significant improvements in postdischarge recovery of performance status.
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- 2022
9. Enhanced Recovery Programs for Colorectal Surgery and Postoperative Acute Kidney Injury: Results From a Systematic Review and Meta-Analysis of Observational Studies
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Andres Zorrilla-Vaca, Juan P. Cata, Michael C. Grant, Ryan Healy, and Gabriel E. Mena
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medicine.medical_specialty ,business.industry ,Acute kidney injury ,General Medicine ,Postoperative recovery ,Perioperative ,Acute Kidney Injury ,medicine.disease ,Colorectal surgery ,Observational Studies as Topic ,Postoperative Complications ,Enhanced recovery ,Meta-analysis ,Anesthesia ,medicine ,Humans ,Observational study ,Enhanced Recovery After Surgery ,business ,Colorectal Surgery - Abstract
Background Enhanced recovery programs (ERPs) for colorectal surgery bundle evidence-based measures to reduce complications, accelerate postoperative recovery, and improve the value of perioperative health care. Despite these successes, several recent studies have identified an association between ERPs and postoperative acute kidney injury (AKI). We conducted a systematic review and meta-analysis to determine the association between ERPs for colorectal surgery and postoperative AKI. Methodology After conducting a search of major databases (PubMed, Embase, Scopus, Google Scholar, and ScienceDirect), we conducted a meta-analysis of observational studies that reported on the association between ERPs and postoperative AKI. Results Six observational studies (n = 4765 patients) comparing ERP (n = 2140) to conventional care (n = 2625) were included. Overall, ERP patients had a significantly greater odds of developing postoperative AKI (odds ratio [OR] = 1.98, 95% confidence interval [CI] 1.31-3.00, P = .001) than those who received conventional care. There was no evidence of publication bias (Begg’s test P = 1.0, Egger’s P value = .95). Conclusions Based upon pooled results from observational studies, ERPs are associated with increased odds of developing postoperative AKI compared to conventional perioperative care. The mechanism for this effect is likely multifactorial. Additional research targeting high risk patient populations should evaluate the role of restrictive fluid administration, hemodynamic goals, and scheduled nephrotoxic agents in ERP protocols.
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- 2020
10. Patient-reported post-discharge opioid use after abdominal gynecologic surgery in an Enhanced Recovery After Surgery (ERAS) program (004)
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Tina S. Suki, M. Sol Basabe, Maria Iniesta-Donate, Gabriel E. Mena, Javier Lasala, Juan E. Garcia Lopez, Katherine Cain, Robert Hillman, Sarah Huepenbecker, Larissa Meyer, and Pedro Ramirez
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Oncology ,Obstetrics and Gynecology - Published
- 2022
11. Surgical universal euglycemic attainment during recovery (SUGAR) initiative: Sweet results through quality improvement (286)
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Jolyn Taylor, Bryan Fellman, Katherine Cain, Maria Iniesta-Donate, Terri Earles, Melinda Harris, Deepthi James, Christine Siebel, Javier Lasala, Gabriel E. Mena, Sally Raty, Shannon Popovich, Khanh Vu, Sonali Thosani, Conor Best, Kathleen Schmeler, Pedro Ramirez, and Larissa Meyer
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Oncology ,Obstetrics and Gynecology - Published
- 2022
12. Updates in Enhanced Recovery Pathways for Gynecologic Surgery
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Andres Zorrilla-Vaca, Javier D. Lasala, and Gabriel E. Mena
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Anesthesiology and Pain Medicine ,Gynecologic Surgical Procedures ,Humans ,Female ,General Medicine ,Enhanced Recovery After Surgery ,Perioperative Care - Abstract
Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.
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- 2022
13. Risk factors for acute kidney injury in an enhanced recovery pathway for colorectal surgery
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Javier Ripollés-Melchor, Gabriel E. Mena, Michael C. Grant, Juan José M. Ramirez-Rodriguez, Juan Victor Lorente, and Andres Zorrilla-Vaca
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medicine.medical_specialty ,Perioperative medicine ,Receiver operating characteristic ,business.industry ,Incidence (epidemiology) ,Acute kidney injury ,Area under the curve ,General Medicine ,Perioperative ,medicine.disease ,female genital diseases and pregnancy complications ,Colorectal surgery ,03 medical and health sciences ,0302 clinical medicine ,030220 oncology & carcinogenesis ,Internal medicine ,medicine ,030211 gastroenterology & hepatology ,Surgery ,business ,Prospective cohort study - Abstract
Enhanced recovery pathways (ERPs) have been disseminated worldwide to improve the perioperative patient outcomes while lowering direct healthcare costs. Recent evidence has revealed a potential association between ERPs for colorectal surgery and acute kidney injury (AKI). We, therefore, sought to identify the risk factors associated with postoperative AKI among patients in an ERP for colorectal surgery. We analyzed the data resulting from a large multicenter, prospective cohort study of patients in an ERP for colorectal surgery. A multivariable analysis was performed to identify factors independently associated with postoperative AKI. The receiver operating characteristic (ROC) curves and contour representations were plotted for the diagnostic prediction analysis. Among those patients included in the analysis (n = 1652), the overall incidence of postoperative AKI was 7.7% (95% CI 6.5–9.1%). After adjustment, the independent risk factors for AKI included age > 60 (OR 1.03, 95% CI 1.01–1.05), male gender (OR 2.33, 95% CI 1.36–4.02), ASA III-IV (OR 2.43, 95% CI 1.39–4.26), CKD (OR 2.45, 95% CI 1.42–4.23), open surgical approach (OR 2.62, 95% CI 1.63–4.21) and serum albumin
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- 2020
14. Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study
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Andres, Zorrilla-Vaca, Pedro T, Ramirez, Maria, Iniesta-Donate, Javier D, Lasala, Xin Shelley, Wang, Loretta A, Williams, Larissa, Meyer, and Gabriel E, Mena
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Analgesics, Opioid ,Cohort Studies ,Pain, Postoperative ,Gynecologic Surgical Procedures ,Humans ,Female ,Ketamine ,Anesthesia ,Patient Reported Outcome Measures ,Dexmedetomidine - Abstract
Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program.We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome.In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053).In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.RéSUMé: OBJECTIF: La dexmédétomidine et la kétamine peuvent être administrées en peropératoire sous forme de perfusions continues pour fournir une anesthésie avec épargne opioïde. Des données probantes récentes ont présenté des résultats controversés concernant l’impact d’une anesthésie sans opioïdes sur les complications postopératoires, et il existe une lacune dans les connaissances concernant les issues rapportées par les patients (IRP). Cette étude visait à déterminer l’impact d’une anesthésie avec épargne opioïde et d’une anesthésie à base d’opioïdes sur les IRP chez les patientes de chirurgie gynécologique dans le cadre d’un programme de Récupération rapide après la chirurgie (ERAS – Enhanced Recovery After Surgery). MéTHODE: Nous avons formé une cohorte historique monocentrique composée de patientes inscrites à une autre étude qui ont bénéficié d’une chirurgie gynécologique avec laparotomie dans le cadre d’un programme d’ERAS entre novembre 2014 et décembre 2020 (n = 2095). Nous avons identifié deux cohortes en fonction du type d’anesthésie équilibrée administrée : 1) anesthésie avec épargne opioïde, définie comme une perfusion continue de dexmédétomidine et de kétamine (adjuvants) pendant la chirurgie, ou 2) anesthésie à base d’opioïdes (sans adjuvants). Nous avons mesuré la qualité de la récupération postopératoire à l’aide de l’inventaire des symptômes MDASI, un outil validé comportant 29 éléments qui a été administré avant l’opération, quotidiennement pendant l’admission et chaque semaine après le congé jusqu’à la semaine 6. Le critère d’évaluation principal était l’interférence avec la marche. Nous avons apparié les deux cohortes et utilisé un modèle linéaire à effets mixtes à plusieurs niveaux pour évaluer l’effet de l’anesthésie avec épargne opioïde sur le critère d’évaluation principal. RéSULTATS: Au total, 498 patientes étaient éligibles (159 dans la cohorte d’anesthésie avec épargne opioïde et 339 dans la cohorte d’anesthésie à base d’opioïdes), dont 149 paires appariées ont été incluses dans l’analyse finale. L’évaluation longitudinale n’a révélé aucune différence significative ou cliniquement importante dans l’interférence avec la marche (P = 0,99), l’activité générale (P = 0,99), ou d’autres IRP entre les deux cohortes. L’administration médiane d’opioïdes peropératoires [écart interquartile (ÉIQ)] (exprimée en équivalents de morphine en milligrammes [EMM]) chez les patientes appariées de la cohorte d’anesthésie avec épargne opioïde était de 30 [25-55] mg vs 58 [8–70] mg dans la cohorte d’anesthésie à base d’opioïdes (P0,01). Les patientes de la cohorte d’anesthésie avec épargne opioïde avaient une consommation d’opioïdes plus faible en salle de réveil que celles de la cohorte d’anesthésie à base d’opioïdes (EMM, 3 [0-10] mg vs 5 [0–15] mg; P0,01), mais il n’y avait pas de différence significative entre les cohortes dans la consommation totale d’opioïdes postopératoires (EMM, 23 [0-94] mg vs 35 [13–95] mg; P = 0,053). CONCLUSION: Dans cette étude de cohorte historique monocentrique, l’anesthésie avec épargne opioïde n’a eu aucun effet significatif ou cliniquement important sur l’interférence avec la marche ou d’autres IRP chez les patientes bénéficiant d’une chirurgie gynécologique par rapport à l’anesthésie à base d’opioïdes. L’anesthésie avec épargne opioïde était associée à une consommation d’opioïdes moindre à court terme que l’anesthésie à base d’opioïdes.
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- 2021
15. EPV259/#288 Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic oncology surgery: a 5-year single center experience
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Pedro T. Ramirez, Maria D. Iniesta, Andres Zorrilla-Vaca, Tina Suki, Larissa A. Meyer, J Garcia-Lopez, J Hayek, Gabriel E. Mena, Javier Lasala, and Katherine E. Cain
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medicine.medical_specialty ,Enhanced recovery ,business.industry ,Medicine ,Gynecologic oncology ,business ,Single Center ,Surgery - Published
- 2021
16. Patient Characteristics Influencing Adherence to Enhanced Recovery Protocols for Colorectal Surgery: a Multicentric Prospective Study
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Andrés Mauricio Galarza-Prado, Andres Zorrilla-Vaca, Ryan Healy, Javier Ripollés, Ane Abad-Motos, Beatriz Nozal-Mateo, Sabela Del Rio, Andrés Fabricio Caballero-Lozada, Alexander Stone, Gabriel E. Mena, and Michael C. Grant
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Postoperative Complications ,Gastroenterology ,Humans ,Surgery ,Coronary Artery Disease ,Guideline Adherence ,Prospective Studies ,Length of Stay ,Colorectal Surgery ,Hypoalbuminemia - Abstract
High compliance within enhanced recovery protocols is associated with lower complication rates. Understanding which clinical characteristics make patients more prone to fail adequate adherence to enhanced recovery after surgery guidelines are essential to improve quality care. Our aim was to identify patient characteristics that influence adherence to enhanced recovery protocols in colorectal surgery.A total of 1041 patients underwent colorectal surgery under ERPs from September 2017 through December 2017 across 21 institutions in Spain. Demographic, medical, and surgical characteristics of the patients included were extracted to determine their influence on the adherence to enhanced recovery protocols. High adherence was defined as ≥ 73% (median). A univariate analysis was performed initially, followed by multivariable logistic regression analysis.Over 85% of the patients underwent colorectal surgery for cancer resection, of which 12% had metastatic disease. In multivariable model, the presence of coronary artery disease (aOR 1.79, 95% CI 1.12-2.96, p = 0.045) was significantly associated with high adherence to enhanced recovery protocols, while preoperative hypoalbuminemia (aOR 0.55, 95% CI 0.37-0.82, p = 0.003), indication for ostomy (aOR 0.55, 95% CI 0.4-0.75, p 0.001), and preoperative transfusion (aOR 0.48, 95% CI 0.26-0.91, p = 0.02) were associated with lower adherence.In this study, patients that had preoperative transfusions, preoperative hypoalbuminemia, and indication for ostomy were more likely to receive care with less adherence to enhanced recovery protocols elements, while patients with coronary artery disease were more likely to receive more enhanced recovery protocols elements during their hospitalization.
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- 2021
17. Association Between Enrollment in an Enhanced Recovery Program for Colorectal Cancer Surgery and Long-Term Recurrence and Survival
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Gabriel E. Mena, Andrés Zorrilla Vaca, Ane Abad-Motos, Alfredo Abad-Gurumeta, Javier Ripollés-Melchor, Nekane Moreno-Jurado, María Luisa de Fuenmayor Varela, Inés Rubiera Mingu, Fátima Martínez-Durán, Isabel Pérez-Martínez, and Michael C. Grant
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Oncology ,medicine.medical_specialty ,business.industry ,General Medicine ,Length of Stay ,Term (time) ,Postoperative Complications ,Enhanced recovery ,Colorectal cancer surgery ,Internal medicine ,medicine ,Humans ,Surgery ,Colorectal Neoplasms ,Enhanced Recovery After Surgery ,business ,Digestive System Surgical Procedures - Abstract
IntroductionEnhanced Recovery After Surgery (ERAS) programs have been shown to minimize the surgical inflammatory response in colorectal cancer, leading to early patient recovery and better postoperative outcomes. Our objective was to determine the association between an ERAS program for colorectal cancer surgery and oncologic recurrence and survival.MethodsA before-after intervention study was designed including patients who underwent colorectal cancer surgery between November 2010 and March 2016. During the study period the institutional criteria for adjuvant therapy remained unchanged and all patients were followed up for 5 years. Cox hazard regression analysis was performed per cumulative year of follow up to evaluate the association between ERAS program exposure and overall survival, cancer-related mortality, and oncologic recurrence. Subgroup analysis was performed by cancer stage (low [I/II] vs advanced [III/IV]).ResultsIn total, 612 patients were included, of which 321 were pre-ERAS and 291 ERAS. Our overall median compliance rate with ERAS interventions was 90% (IQR 85%-95%). Overall survival rates were higher in the ERAS group within the first 2-years after surgery (89.2% vs 83.2%, P=0.04), but there was no difference at 5-year follow up (73.3% vs 72.5%, P=0.82). Subgroup analysis revealed the ERAS enrollment was associated with a significantly lower risk in 5-year oncologic recurrence (aHR 0.55, 95%CI 0.33-0.94, P=0.03) and higher 4-year survival (aHR 0.59, 95%CI 0.37-0.93, P=0.02) among patients with advanced cancer stage compared to pre-ERAS counterparts. ConclusionsPatients with advanced colorectal cancer were less likely to suffer oncologic recurrence when managed during the ERAS period. Additional prospective trials are necessary to determine causation and identify best practice principles associated with long-term recurrence and survival.
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- 2021
18. Goal-Directed Fluid Therapy Does Not Have an Impact on Renal Outcomes in an Enhanced Recovery Program
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Andres Zorrilla-Vaca, Juan P. Cata, Jessica K. Brown, Reza J. Mehran, David Rice, and Gabriel E. Mena
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Pulmonary and Respiratory Medicine ,Postoperative Complications ,Humans ,Fluid Therapy ,Surgery ,Length of Stay ,Cardiology and Cardiovascular Medicine ,Kidney ,Goals - Abstract
Goal-directed fluid therapy (GDFT) has been proposed as a cornerstone for enhanced recovery after surgery (ERAS) programs, particularly among high-risk patients undergoing high-risk surgery. However, because of the increased advocacy of euvolemia before surgery, the utility of GDFT in the context of ERAS is being questioned. Our primary objective was to determine whether GDFT has any impact on daily postoperative renal outcomes of high-risk patients undergoing thoracic surgery in an ERAS program.All patients included in this study were at high risk with a baseline glomerular filtration rate (GFR) below 90 mL/min per 1.73 mIn total, 451 matched pairs were included in this analysis. Both groups had similar demographic and clinical characteristics. Patients treated with GDFT received more ephedrine (5 [0-15] mg vs 0 [0-15] mg; P = .03) and less volume of fluids (1163 ± 484 mL vs 1246 ± 626 mL; P = .03) compared with those in the standard group. The incidence of acute kidney injury was similar in both groups (5.1% in the GDFT group vs 7.1% in the non-GDFT group; P = .57). Mixed effect analysis showed no significant differences in the trajectory of postoperative GFRs between groups (P = .59).GDFT does not have an impact on postoperative renal function compared with standard of care among high-risk patients in an ERAS program for thoracic pulmonary surgery.
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- 2021
19. HERO-Trial: Integration of self-hypnosis in an enhanced recovery after surgery program: A prospective randomized trial (115)
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Larissa Meyer, Maria Iniesta-Donate, Mark Munsell, M. Sol Basabe, Tina S. Suki, Javier Lasala, Gabriel E. Mena, Aaron Shafer, Amir Jazaeri, Xin Shelley Wang, Lorenzo Cohen, and Pedro Ramirez
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Oncology ,Obstetrics and Gynecology - Published
- 2022
20. Sustained reduction of discharge opioid prescriptions in an enhanced recovery after thoracic surgery program: A multilevel generalized linear model
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Boris Sepesi, Gabriel E. Mena, Reza J. Mehran, David C. Rice, Garrett L. Walsh, Jessica K. Brown, Mara B. Antonoff, Ara A. Vaporciyan, Carin A. Hagberg, Wayne L. Hofstetter, Andres Zorrilla-Vaca, and Stephen G. Swisher
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Male ,medicine.medical_specialty ,Analgesic ,Drug Prescriptions ,medicine ,Humans ,Pain Management ,Opioid Epidemic ,Practice Patterns, Physicians' ,Aged ,Retrospective Studies ,Pain, Postoperative ,business.industry ,Middle Aged ,Thoracic Surgical Procedures ,Hydromorphone ,Patient Discharge ,Ketorolac ,Analgesics, Opioid ,Opioid ,Hydrocodone ,Cardiothoracic surgery ,Anesthesia ,Surgery ,Female ,Tramadol ,business ,Enhanced Recovery After Surgery ,Oxycodone ,medicine.drug - Abstract
Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P.001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P.001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.
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- 2021
21. Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis
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Andres, Zorrilla-Vaca, Gabriel E, Mena, Pedro T, Ramirez, Bradley H, Lee, Alexandra, Sideris, and Christopher L, Wu
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Analgesics, Opioid ,Analgesics ,Pain, Postoperative ,Elective Surgical Procedures ,Humans ,Pain Management - Abstract
Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills.The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months.In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%).Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.
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- 2021
22. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update
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Pedro T. Ramirez, Javier Lasala, Eleftheria Kalogera, Larissa A. Meyer, Gretchen E. Glaser, Olle Ljungqvist, Michael J. Scott, Kevin M. Elias, Chelsia Gillis, Jonas Nygren, Jeffrey Huang, Jolyn S. Taylor, Gabriel E. Mena, Alon D. Altman, Jamie N. Bakkum-Gamez, Gregg Nelson, Lena Wijk, Sean C. Dowdy, and Maria D. Iniesta
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medicine.medical_specialty ,Intra operative ,Genital Neoplasms, Female ,business.industry ,General surgery ,Obstetrics and Gynecology ,General Medicine ,Gynecologic oncology ,Guideline ,Preoperative care ,Perioperative Care ,Gynecologic Surgical Procedures ,Oncology ,Perioperative care ,Humans ,Medicine ,Female ,Enhanced Recovery After Surgery ,business ,Enhanced recovery after surgery - Abstract
BackgroundThis is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.MethodsA database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.ResultsAll recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.ConclusionsThe updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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- 2019
23. Institutional factors associated with adherence to enhanced recovery protocols for colorectal surgery: Secondary analysis of a multicenter study
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Andres Zorrilla-Vaca, Alexander B. Stone, Javier Ripolles-Melchor, Ane Abad-Motos, Jose M. Ramirez-Rodriguez, Patricia Galan-Menendez, Gabriel E. Mena, Michael C. Grant, Cristina Garcia-Perez, Eva Higuera-Míguelez, José M. Marcos-Vidal, María Merino-García, Ana B. Rubio-López, María E. Pascual-Diez, Francisco J. García-Miguel, Luis R. Cabezudo-Sanjose, Ruth Martínez-Díaz, Sara Alegría-Rebollo, José L. González-Rodríguez, María S. Vega-Cruz, Gema Martínez-Ragüés, Manuel A. Gómez-Ríos, Eva Mosquera-Rodríguez, Sara Del-Río-Regueira, Domingo Bustos-García, María P. Sánchez-Conde, Antonio Rodríguez-Calvo, María A. Hernández-Valero, María Angoso-Clavijo, Luis M. González-Fernández, Miguel A. Bravo-Riaño, María V. Arnes-Muñoz, José R. Perez-Valdivieso, Marta Martin-Vizcaino, Susana Hernandez-Garcia, Francisco J. Yoldi-Murillo, Miguel Salvador-Bravo, Manuela Rubial-Alvarez, Fabiola Oteiza-Martinez, Enrique Balen-Rivera, José A. Garcia-Erce, Ana Zugasti-Murillo, María E. Petrina-Jáuregui, Filadelfo Bustos-Molina, Daniel Paz-Martín, Bárbara Vázquez-Vicente, Lourdes González-López, Conrado Mínguez-Marín, Susana Diz-Jueguen, Jaime Seoane-Antelo, Julio Ballinas-Miranda, Ester Carrera-Dacosta, Erica Barreiro-Domínguez, Alexandra Piñeiro-Teijeiro, Raquel Sanchez-Santos, Marina Varela-Duran, Pilar Diaz-Parada, Aránzazu Calero-Lillo, Manuel Ángel López-Lara, Salvador Muñoz-Collado, Juan Valverde-Sintas, Silvia Aznar-Puig, Daniel Troyano-Escribano, Sandra Marmaña-Mezquita, Jesús Fernanz-Antón, Lucia Catot-Alemany, Jaume Balust, Marta Ubré, Carlos Ferrando-Ortolá, Graciela Martínez-Pallí, Ainitze Ibarzabal, Antonio M. Lacy, Rubén Sánchez-Martín, Karina Martins-Cruz, Paula Pérez-Jiménez, Rubén Casans-Francés, Javier Longás, José M. Ramírez Rodríguez, Ana Mugarra-Llopis, Cristina Crisan, Estefanía Gracia-Ferrándiz, Esther Romero-Vargas, Marina Soro-Domingo, Rita Rodríguez-Jiménez, Blanca Prada-Martin, Henar Muñoz-Hernández, José I. Gómez Herrera, Sara Cocho-Crespo, Sandra Fernández-Caballero, Miguel Flores-Crespo, Andrea Vázquez-Fernández, Carlo Brugiotti, Estefanía Ollé-Sese, Carla R. Houghton-Acuña, Marta López-Doucil, Ernesto A. Tarazona-López, Iván BEL-Marcobal, Sonia González-Cogollor, Manuel Llácer-Pérez, Alberto Arias-Romano, María C. Arrabal-Taborda, Mercedes Caballero-Domínguez, Rafael García-López, Julio Ontoria-Muriel, Antonio Vivó-Blasco, Francisco J. Blanco, Enrique DEL-Cojo-Peces, Jose M. Tena-Guerrero, Aitor Landaluce-Olavarria, Izaskun Badiola, Marta Calvo, Unai DE-Andres, Vicente Portugal-Porras, Bakarne Ugarte-Sierra, Ana Pedregosa-Sanz, Laura Perelló-Cerdà, Yobanys Rodríguez-Téllez, Joanna Grössl-Meleán, Xavier Viñas-Truñén, Enrique Alday-Muñoz, Elena Bermejo-Marcos, Pedro A. Alonso-Casado, Francisco A. Gimeno-Calvo, Ana Rodriguez-Sánchez, Carmen Montes-López, Laura Álvarez-Llano, María J. FAS-Vicent, Juan M. Ortega-Monzó, Gustavo Flores-Flores, José L. Tristancho, Montserrat Bayo-Sans, María C. Deiros-Garcia, María L. GIL-Gómez, Lourdes Parra, Vanesa Tejedor-DE-LA-Fuente, Carlos Jericó-Alba, Núria Borrell-Brau, David Camacho-Martín, Jose L. Ortiz-DE-Zarate, Daniel López-Ruiz, Vicens Rodriguez-Bustamante, M. Martinez-Vilalta, Daniel Amoros-Ruiz, Marc Sadurni-Sarda, Fernando A.L.C.A.L.D.E. Matas, Hernán Giordano, Jose M. Perez Peña, Luis Olmedilla-Arnal, Pilar Benito-SAZ, Elena López-GIL, Adela Ruiz-Ortega, Sara Zapatero-García, Emilio DEL-Valle-García, Víctor Soria-Aledo, Carmen V. Pérez-Guarinos, Enrique Pellicer-Franco, Graciela Valero-Navarro, Mónica Mengual-Ballester, José Andrés García-Marín, Manuel Romero-Simó, Ibán Caravaca-García, Teresa Blasco-Segura, Carlos F. Campo-Betancourth, Rafael David Costa-Navarro, Laura Jordá-Sanz, María I. DE-Miguel-Cabrera, José M. España-Pamplona, Silvia GIL-Trujillo, Francisco J. Redondo-Calvo, Víctor Baladrón-Gónzalez, Remedios Moreno-Ballesteros, José L. Muñoz-Rodes, Elena Miranda, Marta Roselló-Chornet, Lourdes Alós-Zaragoza, Juan Catalá-Bauset, María A. Pallardo-López, Noemí Almenara-Almenara, Lorena Muñoz-Devesa, Benito Alcaide-Pardo, Pablo Gimeno-Fernández, José L. Gómez-Agraz, Carla Iglesias-Morales, Paola B. Ordoñez-Enireb, Ana M. Ríos-Villalba, Joselvy Rodríguez-Pinto, Sergio Sánchez-Cortés, María J. Montoya-Tabares, Vicente Ruiz, Francisco González-Sánchez, Víctor Soriano-Giménez, José M. Muñoz-Camarena, Jorge Benavides-Buleje, Juan C. Estupiñán-Jiménez, Irene Portero-Larragueta, David Alias, María J. Alberola-Estellés, Óscar Díaz-Cambronero, María S. Matoses-Jaén, María D. Ruiz-Boluda, Carlos Maristany-Bienert, José A. Pardo-López, Álvaro Ramiro-Ruiz, Pablo García, Arantza Martínez-DE-Guereñu, Belinda Montalbán, Claudia Olea, David Benguría, Javier Silva, Adriana Calderón, Jordi Escoll-Rufino, Carlos Cerdan-Santacruz, José E. Sierra-Grañón, María Rufas-Acín, Nuria Mestres-Petit, Ingrid C. Penagos-Saavedra, Cristina Moreno-Castilla, Jordi Riera-RIU, Ana Cuellar-Martínez, R.C. González-Álvarez, Míriam Sánchez-Merchante, Santiago García-DEL-Valle-Y-Manzano, Sara García-Zamorano, Natalia Gijón-Herreros, Patricia Robles-Ángel, Margarita Logroño-Ejea, Rodrigo Sanllorente-Sebastian, Maria C. Villalain-Perez, Mihaela Siclama-Stroe, Judith Benítez-Villar, Alberto Sánchez-Campos, Alberto Martínez-Ruiz, Patricia Alonso-Carnicero, Francisco J. DE-LA-Torre-González, Carolina Naranjo-Checa, Fernando Pereira-Pérez, Elena Ruiz-Ucar, Alfredo Rivera, Cristina GIL-Lapetra, Enrique Roca-Castillo, María L. Mariscal-Flores, Mario Morales-Cayuela, Irene Alonso-Ramos, Virginia Jiménez-Carneros, Lucas Casalduero-Garcia, Javier Jimenez-Miramón, L. José, Eva M. Nogués-Ramia, Yolanda Sosa-Quesada, Alonso Gómez, Laura M. Martínez-Meco-Ortiz, Mercedes Cabellos-Olivares, José R. Rodríguez-Fraile, María Labalde-Martínez, null Ramos-Rodríguez, Beatriz Nacarino-Alcorta, Raquel Fernández-García, Borja DE-LA-Quintana-Gordon, Justyna Drewniak, Fátima Senra-L, Pablo Galindo-Jara, Ana B. Gallardo-Herrera, Cesar García-Llorente, Laura Colao-García, Luz-Divina Rellan-Álvarez, Miguel Miro-Murillo, Sahely-CLARET Flores-Risco, Jordi Serrat-Puyol, Adrian Medina-Gallardo, Yuhami Mitsahid-Curbelo-Peña, null Orenzana, Alfredo Abad-Gurumeta, Norma Aracil-Escoda, Eugenio Martínez-Hurtado, Beatriz Nozal-Mateo, Elena Sáez-Ruiz, Rut Salvachua-Fernández, Javier Ripollés-Melchor, María L. DE-Fuenmayor-Valera, Elena Sánchez, Begoña Toribio, Antonio Navarro-Sánchez, José López-Fernández, Dácil Montesdeoca-Cabrera, Francisco J. Alcalá-Serrano, Azahara Sancho-DE-Avila, Sofia Diaz-Carrasco, Almudena Martín-Martín, Alejandro Suarez-DE-LA-Rica, Rafael UÑA-Orejón, Emilio Maseda, Guillermo Tejón-Pérez, María V. Alfaro-Martínez, Marta Alonso-Fernández, María A. Álvarez-Cebrián, María J. Álvarez-DEL-Vayo-Rodríguez, Mariana Carrillo-Rivas, María Fernández-Rodríguez, Sonia Trabanco-Morán, José L. Rábago-Morán, Javier Martínez-Ubieto, Ana M. Pascual-Bellosta, Sonia M. Ortega-Lucea, Maria P. Santero-Ramirez, Maria V. Duque-Mallen, Cristian Aragon-Benedi, Andrea Vallejo-Tarrat, Carmen Colillas-Calvet, Maria J. Laso, Javier Martinez-Cabañero, Javier Hernández-Salván, Beatriz Ledesma-Muñoz, Carolina Ochoa-Osorio, Máximo Sanz-García, Begoña Herrero-Garrote, Alma Blázquez-Martin, Manuel Díez-Alonso, Pilar Hernández-Juara, José M. Muguerza-Huguet, Macarena Barbero-Mielgo, Belén SAN-Antonio-SAN-Román, Laura Alonso-Aguilar, Viktoria Molnar, María C. Delgado-Naviero, Encarnación Meléndez-Leal, Virginia Cavero-García, África Fernández-Sánchez, Daniela A. Cubek-Quevedo, Rocío D.Í.E.Z. Munar, Francisco J. Blázquez-Fernández-DE-LA Pradilla, Ana B. Serrano, Alberto Balvís, Alberto Berruezo, Elena Esparza, Inés D.E.L.A. HOZ, Ana Palavicini, Lucia Pereira, Ximena Vega, Judith Villahoz, Gema Villanueva, José I. Alonso-Fernández, César Aldecoa, Clara Bolaño-Pérez, Teresa Villán-González, Astrid Batalla, G. Azparren, M. Basttita, M. Felipe, L. Cueva, Marta Gine, A.M. Gómez-Caro, I. India, S. Piñol, Neus Esteve-Pérez, Carlos Mora-Fernández, Ana Ferrer-Robles, Juan J. Segura-Sampedro, Natalia Alonso-Hernández, Angels Camps-Cervantes, Ivette Chocrón-DA-Prat, Carolina C. Coronado-Silva, Héctor Duque-Santos, Elena Esclapez-Sempere, Patricia Galan-Menéndez, Silvia Matarín-Olmo, M.P. Tormos-Pérez, Laura Villarino-Villa, Héctor Bergés-Gutiérrez, Miguel Aisa-Gasca, Verónica Arbona-Camillero, José D. Bautista-González, Francisco J. Carballido-Pascual, Mercedes Gutiérrez-Moreno, Ana Muñoz-Durán, Jesús Cañete-Gómez, Esther Cáceres-Fabrega, José M. Lorente-Herce, Octavio Mulet-Zayas, Rocío Gómez-Pérez, Cristina Monje-Salazar, Luis Lobato-Bancalero, Carmelo Torres-Moreno, Elena Sanchez-Cárdenas, Juan J. Daza-González, Teresa Sanchez-Viguera, Antonio DEL-Fresno-Asensio, Laura Bermudez-Román, José L. Jover-Pinillos, Francisco J. Orts-Micó, Coral Cózar-Lozano, Olga Blasco-Delgado, Andrea Nonnemacher-SAN-Julián, José A. Pérez, Laura D.U.R.Á.N. Cruces, and Pablo Renedo-Corcóstegui
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medicine.medical_specialty ,Perioperative medicine ,Quality management ,business.industry ,Colorectal surgery ,03 medical and health sciences ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,Patient satisfaction ,Enhanced recovery ,030202 anesthesiology ,Multidisciplinary approach ,Spain ,Anesthesiology ,Anesthesia ,Secondary analysis ,Emergency medicine ,Medicine ,Humans ,Multicenter Studies as Topic ,030212 general & internal medicine ,business ,Colorectal Surgery - Abstract
Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery.A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence.The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P 0.01) were negatively associated with adherence.Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.
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- 2021
24. Goal-Directed Fluid Therapy and Postoperative Outcomes in an Enhanced Recovery Program for Colorectal Surgery: A Propensity Score-Matched Multicenter Study
- Author
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Javier Ripollés-Melchor, Ane Abad-Motos, Gabriel E. Mena, Juan Victor Lorente, Andres Zorrilla-Vaca, José Manuel Ramírez-Rodríguez, Cesar Aldecoa, and Michael C. Grant
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Male ,medicine.medical_specialty ,Matched-Pair Analysis ,Colonic Diseases ,Postoperative Complications ,Fluid therapy ,Enhanced recovery ,Clinical Protocols ,medicine ,Humans ,Prospective Studies ,Propensity Score ,Digestive System Surgical Procedures ,Aged ,Perioperative medicine ,business.industry ,General Medicine ,Acute Kidney Injury ,Middle Aged ,Colorectal surgery ,Surgery ,Rectal Diseases ,Multicenter study ,Propensity score matching ,Fluid Therapy ,Female ,business ,Enhanced Recovery After Surgery ,Perfusion - Abstract
Introduction Goal-directed fluid therapy (GDFT) has increasingly been utilized in major surgery as a key component to ensure fluid optimization and adequate tissue perfusion, showing improvements in the rate of morbidity and mortality under conventional care. It is unclear if patients derive similar benefit as part of an enhanced recovery program (ERP). Our group sought to assess the association between GDFT and postoperative outcomes within an ERP for colorectal surgery. Methods A propensity score-matched analysis, based upon demographic characteristics, comorbidities, and ERP components, was utilized to assess the association between GDFT and outcomes in a multicenter prospective ERP for colorectal surgery cohort study. Outcomes included pulmonary edema, acute kidney injury (AKI), ileus, surgical site infection (SSI), and anastomotic dehiscence. The calipmatch module was used to match patients who received GDFT to non-GDFT in a 1‐to‐1 propensity score fashion. Results A total of 151 matched pairs were included in the analysis (n = 302, 23%). Both groups had comparable baseline demographics, as well as similar rates of compliance with enhanced recovery after surgery (ERAS) components. Goal-directed fluid therapy patients received significantly more colloid (237 ± 320 mL vs. 140 ± 245 mL, P < .01) than non-GDFT counterparts. Goal-directed fluid therapy was not associated with improved rates of postoperative AKI (odds ratios (OR) 1.00, 95% confidence intervals (CI) .39-2.59, P = 1.00), ileus (OR 1.40, 95% CI .82-2.41, P = .22), SSI (OR 1.06, 95% CI .54-2.08, P = .86), or length of hospital stay (LOS) (10.8 ± 8.9 vs. 11.1±13.2 days, P = .84). Conclusions There was no associated between GDFT and major postoperative outcomes within an ERAS program for colorectal surgery. Additional large-scale or pragmatic randomized trials are necessary to determine whether GDFT has a role in ERP for colorectal surgery.
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- 2020
25. 350 Factors associated with acute kidney injury in patients undergoing open gynecologic surgery on an enhanced recovery after surgery pathway
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Maria D. Iniesta, Brandelyn Pitcher, Larissa A. Meyer, Javier Lasala, Pedro T. Ramirez, Micah Vaughn, Gabriel E. Mena, and Sarah P. Huepenbecker
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medicine.medical_specialty ,urogenital system ,business.industry ,Incidence (epidemiology) ,Acute kidney injury ,urologic and male genital diseases ,medicine.disease ,female genital diseases and pregnancy complications ,Matched cohort ,Blood loss ,Internal medicine ,Propensity score matching ,medicine ,Rifle ,In patient ,business ,Enhanced recovery after surgery - Abstract
Introduction Enhanced recovery after surgery (ERAS) pathways use goal-directed fluid therapy (GDT) to reduce postoperative complications from fluid imbalance. Our study aimed to determine the incidence and risks of acute kidney injury (AKI) in patients on an ERAS pathway. Methods AKI was defined as acute risk, injury, or failure by RIFLE criteria. Chi-squared, Fisher’s Exact, and Wilcoxon rank-sum tests were used. Propensity score analysis with 1:1 matching compared AKI in ERAS and pre-ERAS cohorts and modeled the probability of AKI as a function of ERAS. Results Among 1127 patients on an ERAS pathway, 140 had AKI (12.4%, 95% CI 10.5%-14.5%). Patients with AKI were more likely to be older (median age 65 vs 57, p Conclusions A total of 12.4% of patients developed AKI, but ERAS itself was not associated with AKI incidence in the matched cohort. Highest AKI risk factors included older age, black race, more comorbidities, and blood loss.
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- 2020
26. Longitudinal patient-reported outcomes and restrictive opioid prescribing after minimally invasive gynecologic surgery
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R. Tyler Hillman, Xin Shelley Wang, Qiuling Shi, Tina Suki, Larissa A. Meyer, Pedro T. Ramirez, Katherine E. Cain, Javier Lasala, Loretta A. Williams, Maria D. Iniesta, Tsun Chen, Gabriel E. Mena, and Jolyn S. Taylor
- Subjects
Adult ,medicine.medical_specialty ,medicine.medical_treatment ,Aftercare ,Malignancy ,Opioid prescribing ,Article ,Gynecologic Surgical Procedures ,Statistical significance ,medicine ,Humans ,Minimally Invasive Surgical Procedures ,Longitudinal Studies ,Patient Reported Outcome Measures ,Practice Patterns, Physicians' ,Aged ,Retrospective Studies ,Aged, 80 and over ,Pain, Postoperative ,Hysterectomy ,business.industry ,Significant difference ,Obstetrics and Gynecology ,Middle Aged ,medicine.disease ,Quality Improvement ,Surgery ,Analgesics, Opioid ,Oncology ,Cohort ,Morphine ,Female ,business ,Oxycodone ,medicine.drug - Abstract
ObjectiveTo determine post-discharge patient-reported symptoms before and after implementation of restrictive opioid prescribing among women undergoing minimally invasive gynecologic surgery.MethodsWe compared clinical outcomes and symptom burden among a cohort of 389 women undergoing minimally invasive gynecologic surgery at a single institution before and after implementation of a restrictive opioid prescribing quality improvement initiative in July 2018. Post-discharge symptom burdens were collected up to 42 days after discharge using the MD Anderson Symptom Inventory and analyzed using linear mixed effects models.ResultsThe majority of women included in this study were white non-smokers and the median age was 55 (range 23–83). Most women underwent hysterectomy (64%), had surgery for malignancy (71%), and were discharged from the hospital on the day of surgery (65%). Women in the restrictive opioid prescribing group had a median reduction in morphine equivalent dose prescribed at discharge of 83%, corresponding to a median reduction in 25 tablets of 5 mg oxycodone per person. There was no difference between opioid prescribing groups in either the rate of refill requests (P=1) or hospital re-admission (P=1) up to 30 days after discharge. After adjustment for co-variates, there was no statistically significant difference in post-discharge symptom burden including patient-reported pain (P=0.08), sleep (P=0.30), walking interference (P=0.64), activity interference (P=0.12), or affective interference (P=0.67). There was a trend toward less reported constiptation in the restrictive opioid prescribing group that did not reach statistical significance (P=0.05).ConclusionWe found that restrictive post-operative opioid prescribing was not associated with differences in longitudinal symptom burden among women undergoing minimally invasive gynecologic surgery. These results provide the most comprehensive picture to date of post-operative symptom recovery under different opioid prescribing approaches, lending additional support for existing recommendations to reduce opioid prescribing following gynecologic surgery.
- Published
- 2020
27. Risk factors for acute kidney injury in an enhanced recovery pathway for colorectal surgery
- Author
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Andrés, Zorrilla-Vaca, Gabriel E, Mena, Javier, Ripolles-Melchor, Juan Victor, Lorente, Juan José M, Ramirez-Rodriguez, and Michael C, Grant
- Subjects
Aged, 80 and over ,Male ,Colon ,Malnutrition ,Age Factors ,Rectum ,Nutritional Status ,Acute Kidney Injury ,Middle Aged ,Postoperative Complications ,ROC Curve ,Risk Factors ,Creatinine ,Humans ,Multicenter Studies as Topic ,Female ,Prospective Studies ,Enhanced Recovery After Surgery ,Digestive System Surgical Procedures ,Serum Albumin ,Aged - Abstract
Enhanced recovery pathways (ERPs) have been disseminated worldwide to improve the perioperative patient outcomes while lowering direct healthcare costs. Recent evidence has revealed a potential association between ERPs for colorectal surgery and acute kidney injury (AKI). We, therefore, sought to identify the risk factors associated with postoperative AKI among patients in an ERP for colorectal surgery.We analyzed the data resulting from a large multicenter, prospective cohort study of patients in an ERP for colorectal surgery. A multivariable analysis was performed to identify factors independently associated with postoperative AKI. The receiver operating characteristic (ROC) curves and contour representations were plotted for the diagnostic prediction analysis.Among those patients included in the analysis (n = 1652), the overall incidence of postoperative AKI was 7.7% (95% CI 6.5-9.1%). After adjustment, the independent risk factors for AKI included age 60 (OR 1.03, 95% CI 1.01-1.05), male gender (OR 2.33, 95% CI 1.36-4.02), ASA III-IV (OR 2.43, 95% CI 1.39-4.26), CKD (OR 2.45, 95% CI 1.42-4.23), open surgical approach (OR 2.62, 95% CI 1.63-4.21) and serum albumin 3.5 g/dL (OR 1.68, 95% CI 1.02-2.79). An ROC analysis revealed that the composite of albumin, creatinine and age was a strong predictor of postoperative AKI [area under the curve (AUC) 0.756; 95% CI 0.705-0.808].Postoperative AKI is common in the setting of ERPs for colorectal surgery and it is associated with a poor clinical outcome. Of those characteristics associated with postoperative AKI, one modifiable factor is a low preoperative albumin level. Screening for malnourished patients or optimizing the nutritional status may be a useful preoperative intervention to prevent postoperative AKI and associated complications.
- Published
- 2020
28. Enhanced recovery for obese patients undergoing gynecologic cancer surgery
- Author
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Ross F. Harrison, Katherine E. Cain, Javier Lasala, Gabriel E. Mena, Larissa A. Meyer, Maria D. Iniesta, Pedro T. Ramirez, Ashley Siverand, and Brandelyn Pitcher
- Subjects
medicine.medical_specialty ,Uterine Cervical Neoplasms ,Patient Readmission ,Article ,Body Mass Index ,Primary outcome ,Postoperative Complications ,Enhanced recovery ,Gynecologic cancer ,medicine ,Humans ,Obesity ,Aged ,Retrospective Studies ,Ovarian Neoplasms ,business.industry ,Obstetrics and Gynecology ,Cancer ,Length of Stay ,Middle Aged ,medicine.disease ,Surgery ,Analgesics, Opioid ,Oncology ,Female ,Complication ,business ,Enhanced Recovery After Surgery ,Cohort study ,Abdominal surgery - Abstract
ObjectiveTo compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery.MethodsWe performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance.ResultsAfter matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48–66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, pConclusionsNeither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.
- Published
- 2020
29. Liposomal Bupivacaine Intercostal Block Is Important for Reduction of Pulmonary Complications
- Author
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Kyle G. Mitchell, Gabriel E. Mena, Ravi Rajaram, Boris Sepesi, Reza J. Mehran, Erin M. Corsini, Jack A. Roth, David C. Rice, Garrett L. Walsh, Nicolas Zhou, Ara A. Vaporciyan, Stephen G. Swisher, Mara B. Antonoff, and Wayne L. Hofstetter
- Subjects
Pulmonary and Respiratory Medicine ,Spirometry ,Male ,Lung Neoplasms ,Respiratory arrest ,Intercostal nerves ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Bronchoscopy ,medicine ,Humans ,Pain Management ,Anesthetics, Local ,Pneumonectomy ,Aged ,Pain Measurement ,Retrospective Studies ,Pain, Postoperative ,medicine.diagnostic_test ,business.industry ,Incidence ,Nerve Block ,Odds ratio ,Middle Aged ,Liposomal Bupivacaine ,medicine.disease ,Bupivacaine ,United States ,Pneumonia ,030228 respiratory system ,Anesthesia ,Surgery ,Female ,Intercostal Nerves ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Intercostal nerve block ,Follow-Up Studies - Abstract
Background We have previously demonstrated that Enhanced Recovery After Surgery protocols are associated with a reduction in pulmonary complications. As a component of enhanced recovery pathways, intercostal nerve blocks with liposomal bupivacaine are increasingly utilized, but the extent to which this element may contribute to such outcomes has not been evaluated. Methods Patients undergoing lung resection for stage I to III non-small cell lung cancer at a single institution from 2006 to 2017 were examined for major postoperative pulmonary morbidity, defined as pneumonia, acute respiratory distress syndrome, respiratory arrest, reintubation, bronchoscopy, or need for discharge with oxygen. Pharmacy records were queried for administration of liposomal bupivacaine via posterior intercostal nerve block. Patients treated with and without liposomal bupivacaine were compared in a logistic regression to determine the impact on pulmonary morbidity. Results A total of 2865 patients were identified, including 860 (30%) who were treated with liposomal bupivacaine via posterior intercostal block. Pulmonary morbidity occurred in 455 (16%). Adoption of liposomal bupivacaine analgesia occurred over several years, beginning in 2012 to full adoption by 2017. Liposomal bupivacaine management was associated with a reduction in pulmonary complications, as compared with nonuse (odds ratio, 0.63; P = .006). Additional factors associated with the occurrence of pulmonary morbidity were age, body mass index, smoking, spirometry values, and operative blood loss. Conclusions As a component of an active enhanced recovery program, liposomal bupivacaine is associated with a reduction in major pulmonary complications, and utilization should be evaluated on a hospital-by-hospital basis.
- Published
- 2020
30. Gynecologic/Oncology Surgery
- Author
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Jamie N. Bakkum-Gamez, Gabriel E. Mena, Michael J. Scott, Sean C. Dowdy, Basile Pache, Gregg Nelson, Javier Lasala, Alon D. Altman, Pedro T. Ramirez, and Larissa A. Meyer
- Subjects
Protocol (science) ,medicine.medical_specialty ,business.industry ,Perioperative care ,Medicine ,Medical physics ,Gynecologic oncology ,Audit ,business ,Enhanced recovery after surgery ,Team development ,Order set - Abstract
The enhanced recovery after surgery (ERAS) gynecologic/oncology guidelines have helped integrate existing knowledge into practice and aligned perioperative care within our discipline. Despite this, many clinical departments still struggle with how to initiate their ERAS program, particularly as it relates to translating the guidelines into an actual protocol. With the goal of addressing this gap, recently Nelson and colleagues published a series of practical recommendations including ERAS order sets and instructions for both ERAS team development and ERAS program audit.
- Published
- 2020
31. Effects of Intraoperative Opioid Use on Recurrence-Free and Overall Survival in Patients With Esophageal Adenocarcinoma and Squamous Cell Carcinoma
- Author
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Wayne L. Hofstetter, Jeel Mehta, Kim N. Du, Javier D Lasala, Gabriel E. Mena, Abigail Newhouse, Juan P. Cata, and Lei Feng
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,Esophageal Neoplasms ,Population ,Adenocarcinoma ,Risk Assessment ,Gastroenterology ,Fentanyl ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,030202 anesthesiology ,Internal medicine ,medicine ,Humans ,Progression-free survival ,Esophagus ,education ,Aged ,Retrospective Studies ,education.field_of_study ,Intraoperative Care ,business.industry ,Hazard ratio ,Perioperative ,Middle Aged ,Esophageal cancer ,medicine.disease ,Progression-Free Survival ,Analgesics, Opioid ,Esophagectomy ,Anesthesiology and Pain Medicine ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Female ,Esophageal Squamous Cell Carcinoma ,business ,medicine.drug - Abstract
BACKGROUND Perioperative opioid use is associated with poor survival in patients with esophageal squamous cell carcinoma. The most common histological type of esophageal cancer in western countries is adenocarcinoma. The objective of this study was to evaluate the association between intraoperative opioid consumption and survival in patients with adenocarcinoma and squamous cell carcinoma of the esophagus. METHODS Records of patients who had undergone esophageal cancer surgery between January 2000 and January 2017 were reviewed. Comparisons were made between patients who received high versus low intraoperative doses of opioids. Groups were divided using the recursive partitioning method. Multicovariate Cox proportional hazards models were fitted to evaluate the impact of intraoperative opioid use on recurrence-free survival (RFS) and overall survival (OS). RESULTS For patients with esophageal squamous cell carcinoma, the univariable analysis indicated that lower opioid dosages (
- Published
- 2018
32. Enhanced Recovery Decreases Pulmonary and Cardiac Complications After Thoracotomy for Lung Cancer
- Author
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Garrett L. Walsh, Reza J. Mehran, Carla M. Baker, Arlene M. Correa, Mara B. Antonoff, Jack A. Roth, Robert M. Van Haren, Gabriel E. Mena, Wayne L. Hofstetter, Ara A. Vaporciyan, Ta Charra Woodard, David C. Rice, Stephen G. Swisher, and Boris Sepesi
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Lung Neoplasms ,Surgical stress ,medicine.medical_treatment ,Cancer Care Facilities ,030204 cardiovascular system & hematology ,Disease-Free Survival ,Perioperative Care ,law.invention ,Cohort Studies ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,law ,medicine ,Humans ,Hospital Mortality ,Thoracotomy ,Lung cancer ,Adverse effect ,Aged ,Retrospective Studies ,business.industry ,Mortality rate ,Recovery of Function ,Perioperative ,Length of Stay ,Middle Aged ,medicine.disease ,Survival Analysis ,Texas ,Intensive care unit ,Surgery ,Pneumonia ,Logistic Models ,Treatment Outcome ,030220 oncology & carcinogenesis ,Multivariate Analysis ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Enhanced recovery after surgery (ERAS) pathways aim to improve postoperative recovery through evidence-based practices, including early ambulation, multimodal opioid-sparing analgesia, and reduction of surgical stress. This study evaluated outcomes after implementation of ERAS in patients undergoing resection for pulmonary malignancy.A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer. Analysis was performed between three periods: pre-ERAS (January 1, 2006, to December 31, 2011), transitional period with elements of ERAS (January 1, 2012, to August 31, 2015), and full implementation of ERAS (September 1, 2015, to December 31, 2016).We analyzed 2,886 lung resections (pre-ERAS, n = 1615; transitional, n = 929; ERAS, n = 342). For all patients, length of stay decreased in the ERAS and transitional periods compared with pre-ERAS (4 [3] versus 4 [3] versus 5 [3] days, p0.001). Pulmonary complications were decreased with ERAS compared with transitional and pre-ERAS (19.9% versus 28.2% versus 28.7%, p = 0.004). Cardiac complications decreased with ERAS (12.3% versus 13.1% versus 18.1%, p = 0.001). There was less thoracic epidural use (2.9% versus 44.5% versus 75.5%, p0.001). There were no differences in hospital readmission (p = 0.772) or mortality rates (p = 0.417). After thoracotomy, ERAS was associated with decreased length of stay, fewer intensive care unit readmissions, and decreased frequency of pneumonia, atrial arrhythmias, and need for home oxygen (all p0.05). ERAS was independently associated with decreased pulmonary (p = 0.046) and cardiac (p = 0.001) complications on logistic regression after thoracotomy but not minimally invasive operations.ERAS was associated with improved postoperative outcomes, including decreased length of stay and pulmonary and cardiac morbidity after thoracotomy, but not after minimally invasive operations. ERAS safety was demonstrated by low rates of adverse events without effect on hospital readmission or perioperative deaths.
- Published
- 2018
33. Single Chest Tube Practice Reduces Discharge Opioid Prescriptions Without Increasing Pulmonary Complications after Thoracic Surgery
- Author
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Gabriel E. Mena, Ara A. Vaporciyan, Ravi Rajaram, David C. Rice, Andres Zorrilla-Vaca, Arlene M. Correa, Hope A. Feldman, Reza J. Mehran, Jessica K. Brown, and Mara B. Antonoff
- Subjects
Chest tube ,medicine.medical_specialty ,Opioid ,business.industry ,Cardiothoracic surgery ,medicine.medical_treatment ,Anesthesia ,Medicine ,Surgery ,Medical prescription ,business ,medicine.drug - Published
- 2021
34. Enhanced recovery after surgery (ERAS®) in gynecologic oncology – Practical considerations for program development
- Author
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Pedro T. Ramirez, Sean C. Dowdy, Gregg Nelson, Gabriel E. Mena, Larissa A. Meyer, Maria D. Iniesta, Jamie N. Bakkum-Gamez, and Javier Lasala
- Subjects
medicine.medical_specialty ,030219 obstetrics & reproductive medicine ,Genital Neoplasms, Female ,business.industry ,Obstetrics and Gynecology ,Gynecologic oncology ,Perioperative Care ,03 medical and health sciences ,Gynecologic Surgical Procedures ,Surgical Oncology ,0302 clinical medicine ,Oncology ,Gynecology ,030220 oncology & carcinogenesis ,Practice Guidelines as Topic ,Humans ,Medicine ,Female ,Program development ,Program Development ,business ,Intensive care medicine ,Enhanced recovery after surgery - Published
- 2017
35. Rate of venous thromboembolism in gynecologic patients on an ERAS pathway
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Maria Iniesta-Donate, Javier Lasala, Jolyn S. Taylor, Larissa A. Meyer, Katherine E. Cain, Pedro T. Ramirez, Andres S. Zorilla Vaca, and Gabriel E. Mena
- Subjects
Cancer Research ,medicine.medical_specialty ,Oncology ,business.industry ,medicine ,Care pathway ,business ,Complication ,Venous thromboembolism ,Enhanced recovery after surgery ,Surgery - Abstract
214 Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.
- Published
- 2021
36. Ketorolac use and anastomotic leak in patients with esophageal cancer
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Mara B. Antonoff, Erin M. Corsini, Stephen G. Swisher, Boris Sepesi, Ara A. Vaporciyan, Nicolas Zhou, David C. Rice, Jack A. Roth, Garrett L. Walsh, Kyle G. Mitchell, Gabriel E. Mena, Reza J. Mehran, and Wayne L. Hofstetter
- Subjects
Pulmonary and Respiratory Medicine ,Male ,medicine.medical_specialty ,Leak ,Endoleak ,Esophageal Neoplasms ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Anastomosis ,Adenocarcinoma ,03 medical and health sciences ,0302 clinical medicine ,Interquartile range ,medicine ,Humans ,Aged ,Retrospective Studies ,Postoperative Care ,business.industry ,Anastomosis, Surgical ,Anti-Inflammatory Agents, Non-Steroidal ,Perioperative ,Odds ratio ,Esophageal cancer ,Middle Aged ,medicine.disease ,Surgery ,body regions ,Ketorolac ,Esophagectomy ,030228 respiratory system ,Female ,Cardiology and Cardiovascular Medicine ,business ,Enhanced Recovery After Surgery ,medicine.drug - Abstract
Objectives Recent evidence has shown an association between postoperative ketorolac use and anastomotic leak in patients undergoing intestinal and colorectal operations, but this relationship has been minimally explored after esophagectomy. As the use of nonopioid pain control and enhanced recovery protocols is increasingly prioritized, determination of a possible correlation between perioperative ketorolac use and leak is essential. Methods Records of patients undergoing esophagectomy for adenocarcinoma at a single institution from 2006 to 2018 reviewed for occurrence of anastomotic leak. Institutional pharmacy records were queried for ketorolac administration during the surgical case through the time of discharge. Multivariable logistic regression was used to determine the relationship between ketorolac administration and anastomotic leak. Results A total of 1019 patients met inclusion criteria, the majority of whom were male (907, 89%) with a median age of 62 years. Patients predominantly presented with locoregionally advanced disease and were treated with initial chemoradiation. Ketorolac was administered to 686 patients (67%); use was observed to increase over the study period from 49% in 2006 to 92% in 2016. Conversely, anastomotic leak occurred in 87 patients (9%) overall and decreased over time from 15% (11/72) in 2006 to 2% (2/83) in 2018. Upon multivariable analysis, neither ketorolac administration evaluated as a categoric variable (odds ratio, 0.99; P = .958) or as a continuous variable using dose (odds ratio, 1.00; P = .843) demonstrated an association with anastomotic leak. Conclusions Ketorolac in the postoperative period after esophagectomy has become an integral component of enhanced recovery pathways and does not appear to be associated with anastomotic leak.
- Published
- 2019
37. Impact of compliance with an enhanced recovery after surgery pathway on patient outcomes in open gynecologic surgery
- Author
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Gabriel E. Mena, Melinda Harris, Andrea Rodriguez-Restrepo, Lakisha D Washington, Gloria Salvo, Maria D. Iniesta, Brandelyn Pitcher, Javier Lasala, Pedro T. Ramirez, and Larissa A. Meyer
- Subjects
Adult ,medicine.medical_specialty ,Adolescent ,Genital Neoplasms, Female ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Gynecologic Surgical Procedures ,Medicine ,Humans ,Enhanced recovery after surgery ,Aged ,Retrospective Studies ,Aged, 80 and over ,030219 obstetrics & reproductive medicine ,business.industry ,Obstetrics and Gynecology ,Middle Aged ,Surgery ,Compliance (physiology) ,Treatment Outcome ,Oncology ,030220 oncology & carcinogenesis ,Female ,Guideline Adherence ,business ,Complication ,Enhanced Recovery After Surgery - Abstract
ObjectiveThe aim of this study was to evaluate if varying levels of compliance with an enhanced recovery after surgery (ERAS) protocol impacted post-operative outcomes (length of stay, complications, readmissions, and re-operations) in gynecologic surgery at a tertiary center.MethodsWe included 584 patients who had open gynecologic surgery between November 1, 2014 and December 31, 2016. Patients were categorized into subgroups according to their date of surgery from the time of the ERAS protocol implementation. Patients were categorized by their per cent compliance into two groups:ResultsOverall compliance was 72.3%. Patients with compliance ≥80% had significantly less complications (PConclusionsCompliance with an ERAS pathway exceeding 80% was associated with lower complication rates and shorter length of stay without impacting on re-operations or readmissions.
- Published
- 2019
38. Determining the Safety and Efficacy of Enhanced Recovery Protocols in Major Oncologic Surgery: An Institutional NSQIP Analysis
- Author
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Pedro T. Ramirez, Barbra B. Speer, David C. Rice, Bradford J. Kim, Javier Lasala, Gabriel E. Mena, Heather A. Lillemoe, Neema Navai, Brian K. Bednarski, Thomas A. Aloia, Vijaya Gottumukkala, Rachel K. Voss, Wendell H. Williams, and Rebecca K. Marcus
- Subjects
Male ,medicine.medical_specialty ,MEDLINE ,030230 surgery ,Article ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,Surgical oncology ,Neoplasms ,Medicine ,Humans ,Survival rate ,Aged ,Protocol (science) ,business.industry ,Medical record ,Recovery of Function ,Middle Aged ,Prognosis ,Colorectal surgery ,Surgery ,Survival Rate ,Surgical Oncology ,Oncology ,030220 oncology & carcinogenesis ,Surgical Procedures, Operative ,Female ,business ,Complication ,Patient education ,Follow-Up Studies - Abstract
BACKGROUND: Enhanced recovery (ER) protocols are increasingly being utilized in surgical practice. Outside of colorectal surgery, however, their feasibility, safety, and efficacy in major oncologic surgery have not been proven. This study compared patient outcomes before and after multispecialty implementation of ER protocols at a large comprehensive cancer center. METHODS: Surgical cases performed from 2011–2016 and captured by an institutional NSQIP database were reviewed. Following exclusion of outpatient and emergent surgeries, 2747 cases were included in the analyses. Cases were stratified by presence or absence of ER compliance, defined by preoperative patient education and electronic medical record order set-driven opioid-sparing analgesia, goal-directed fluid therapy, and early postoperative diet advancement and ambulation. RESULTS: Approximately half of patients were treated on ER protocols (46%) and the remaining on traditional postoperative (TP) protocols (54%). Treatment on an ER protocol was associated with decreased overall complication rates (20% vs. 33%, p
- Published
- 2019
39. Enhanced Recovery After Surgery (ERAS) for Thoracic Surgery
- Author
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Lavinia Kolarczyk, Javier Lasala, Gabriel E. Mena, and Emily G. Teeter
- Subjects
Fight-or-flight response ,medicine.medical_specialty ,Multidisciplinary approach ,business.industry ,Cardiothoracic surgery ,Prehabilitation ,Core component ,General surgery ,Perioperative care ,Medicine ,Functional status ,business ,Enhanced recovery after surgery - Abstract
Enhanced recovery after surgery (ERAS) is a multidisciplinary, comprehensive approach to perioperative care that aims to mitigate the stress response to surgery, thus enabling a smoother recovery and faster return to baseline functional status. While still an emerging concept in thoracic surgery, ERAS is comprised of core components that span the pre-operative, intraoperative, and post-operative arenas. The involvement of the anesthesiologist is vital to the success of a thoracic ERAS program. Here we will review the background and core tenets of ERAS, the available literature related to specific components, the barriers to implementation, and the direction for future efforts in this field.
- Published
- 2019
40. A prospective randomized trial comparing liposomal bupivacaine vs standard bupivacaine wound infiltration in open gynecologic surgery on an enhanced recovery pathway
- Author
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Javier Lasala, Maria D. Iniesta, Pedro T. Ramirez, Qiuling Shi, Camila Corzo, Xin Shelly Wang, Mark F. Munsell, Katherine E. Cain, Gabriel E. Mena, Brandelyn Pitcher, and Larissa A. Meyer
- Subjects
Adult ,medicine.medical_specialty ,Exploratory laparotomy ,medicine.medical_treatment ,law.invention ,Young Adult ,03 medical and health sciences ,Gynecologic Surgical Procedures ,0302 clinical medicine ,Randomized controlled trial ,law ,Laparotomy ,medicine ,Humans ,Single-Blind Method ,Prospective Studies ,030212 general & internal medicine ,Anesthetics, Local ,Syringe ,Aged ,Pain Measurement ,Aged, 80 and over ,Bupivacaine ,Pain, Postoperative ,Wound Healing ,030219 obstetrics & reproductive medicine ,business.industry ,Obstetrics and Gynecology ,Middle Aged ,Liposomal Bupivacaine ,Surgery ,Treatment Outcome ,Opioid ,Liposomes ,Morphine ,Female ,business ,medicine.drug - Abstract
Background Value in healthcare is reflected by patient-centered outcomes of care per health dollar expended. Although liposomal bupivacaine is more expensive, it has been shown to provide prolonged analgesia (up to 72 hours). Objective This study aimed to evaluate whether the addition of liposomal bupivacaine to standard bupivacaine could decrease opioid intake and improve pain control after laparotomy for gynecologic surgery compared with standard bupivacaine alone in an enhanced recovery after surgery pathway. Study Design A prospective randomized controlled single-blinded trial of wound infiltration with liposomal bupivacaine plus 0.25% bupivacaine (study arm) vs 0.25% bupivacaine (control arm) was performed at a National Cancer Institute–designated tertiary referral cancer center. Participants were patients aged ≥18 years undergoing exploratory laparotomy for a gynecologic indication. All patients were treated on an enhanced recovery pathway including local wound infiltration before closure. In this study, 266 mg of liposomal bupivacaine (free base; equal to 300 mg bupivacaine HCL)+150 mg of bupivacaine mixed in the same syringe was used in the study arm, and 150 mg of bupivacaine was used in the control arm. The primary outcome was the proportion of patients who were opioid-free within 48 hours after surgery. Secondary outcomes included number of opioid-free days from postoperative day 0 to postoperative day 3, days to first opioid administration, morphine equivalent daily dose, and patient-reported outcomes collected with the MD Anderson Symptom Inventory. The MD Anderson Symptom Inventory was administered as a preoperative baseline, daily while hospitalized, and at least weekly for 8 weeks after discharge. All outcomes were prespecified before data collection. Results In this study, 102 patients were evaluated. Among them, 16.7% of patients in the study arm received no opioids up to 48 hours compared with 14.8% in the control arm (P=.99). There were no significant differences in the amount of intraoperative opioids administered or days to first opioid use. There was no significant difference between the 2 arms in median cumulative morphine equivalent daily dose (21.3 [study arm] vs 33.8 [control arm]; P=.36) or between the groups in morphine equivalent daily dose per individual day. There were no significant differences in patient-reported pain or interference with walking between the 2 arms or other patient-reported outcomes. Conclusion Within an enhanced recovery after surgery pathway, adding liposomal bupivacaine to 0.25% bupivacaine wound infiltration did not decrease the proportion of patients who were opioid-free within 48 hours after surgery, did not decrease opioid intake, or did not improve patient’s self-reported pain and functional recovery compared with standard bupivacaine.
- Published
- 2021
41. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs
- Author
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Maria Iniesta-Donate, Juan P. Cata, Javier Lasala, Alpa M. Nick, Vijaya Gottumukkala, Ester Miralpeix, Larissa A. Meyer, Gabriel E. Mena, Pedro T. Ramirez, and Gloria Salvo
- Subjects
medicine.medical_specialty ,Standard of care ,Genital Neoplasms, Female ,MEDLINE ,Gynecologic oncology ,Perioperative Care ,Article ,03 medical and health sciences ,Gynecologic Surgical Procedures ,Postoperative Complications ,0302 clinical medicine ,Health care ,medicine ,Humans ,Intensive care medicine ,Enhanced recovery after surgery ,Randomized Controlled Trials as Topic ,030219 obstetrics & reproductive medicine ,business.industry ,Obstetrics and Gynecology ,Standard of Care ,Perioperative ,Colorectal surgery ,Oncology ,030220 oncology & carcinogenesis ,Female ,Fast track ,business - Abstract
Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).
- Published
- 2016
42. Factors associated with acute kidney injury (AKI) in patients undergoing surgery on an enhanced recovery after surgery pathway
- Author
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Brandelyn Pitcher, Maria D. Iniesta, Micah Vaughn, Larissa A. Meyer, Javier Lasala, Pedro T. Ramirez, and Gabriel E. Mena
- Subjects
medicine.medical_specialty ,Oncology ,business.industry ,medicine ,Acute kidney injury ,Obstetrics and Gynecology ,In patient ,business ,medicine.disease ,Enhanced recovery after surgery ,Surgery - Published
- 2020
43. Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist
- Author
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Juan P. Cata, Wendell H. Williams, Gabriel E. Mena, and Javier Lasala
- Subjects
medicine.medical_specialty ,Thymoma ,medicine.medical_treatment ,Cholinergic crisis ,Neuromuscular transmission ,030204 cardiovascular system & hematology ,Sugammadex ,03 medical and health sciences ,0302 clinical medicine ,030202 anesthesiology ,Monitoring, Intraoperative ,Myasthenia Gravis ,Preoperative Care ,medicine ,Anesthesia, Cardiac Procedures ,Humans ,Mechanical ventilation ,business.industry ,Perioperative ,Thymus Neoplasms ,medicine.disease ,Thymectomy ,Myasthenia gravis ,Surgery ,Anesthesiologists ,Anesthesiology and Pain Medicine ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.
- Published
- 2018
44. Posterior Intercostal Nerve Block With Liposomal Bupivacaine: An Alternative to Thoracic Epidural Analgesia
- Author
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Andrea Rodriguez-Restrepo, David C. Rice, Juan P. Cata, Reza J. Mehran, Gabriel E. Mena, and Arlene M. Correa
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,Thoracic Surgical Procedure ,Narcotic ,medicine.medical_treatment ,Intercostal nerves ,Injections ,medicine ,Humans ,Anesthetics, Local ,Pain Measurement ,Retrospective Studies ,Pain, Postoperative ,business.industry ,Urinary retention ,Nerve Block ,Perioperative ,Middle Aged ,Thoracic Surgical Procedures ,Bupivacaine ,Surgery ,Blockade ,Analgesia, Epidural ,Cardiothoracic surgery ,Anesthesia ,Liposomes ,Female ,Intercostal Nerves ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies ,Intercostal nerve block - Abstract
Background Pain relief using regional neuroaxial blockade is standard care for patients undergoing major thoracic surgery. Thoracic epidural analgesia (TEA) provides effective postoperative analgesia but has unwanted side effects, including hypotension, urinary retention, nausea, and vomiting, and is highly operator dependent. Single-shot intercostal nerve and paravertebral blockade have not been widely used because of the short duration of action of most local anesthetics; however, the recent availability of liposomal bupivacaine (LipoB) offers the potential to provide prolonged blockade of intercostal nerves (72 to 96 hours). We hypothesized that a five-level unilateral posterior intercostal nerve block using LipoB would provide effective analgesia for patients undergoing thoracic surgery. Methods We identified patients who underwent lung resection using intraoperative LipoB posterior intercostal nerve blockade and retrospectively compared them with a group of patients who had TEA and who were matched for age, sex, type of surgery, and surgical approach. We analyzed perioperative morbidity, pain scores and narcotic requirements. Results There were 54 patients in each group. Mean hospital stay was 3.5 days and 4.5 days ( p = 0.004) for LipoB group and TEA group, respectively. There were no significant differences in perioperative complications, postoperative pain scores, or in narcotic utilization between LipoB group and TEA group. No acute toxicity related to LipoB was observed. Conclusions Posterior intercostal nerve blockade using LipoB is safe and provides effective analgesia for patients undergoing thoracic surgery. It may be considered as a suitable alternative to TEA.
- Published
- 2015
45. Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer
- Author
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Juan P. Cata, Javier Lasala, Gabriel E. Mena, and John R Mehran
- Subjects
medicine.medical_specialty ,Lung Neoplasms ,Tumor Staging ,030204 cardiovascular system & hematology ,Mediastinoscopy ,Mediastinal staging ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Thoracoscopy ,Humans ,Anesthesia ,Lung cancer ,Ultrasonography, Interventional ,Neoplasm Staging ,Lung ,medicine.diagnostic_test ,business.industry ,Thoracic Surgery, Video-Assisted ,Mediastinum ,medicine.disease ,Anesthesiology and Pain Medicine ,medicine.anatomical_structure ,030228 respiratory system ,Lung tumor ,Narrative review ,Radiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.
- Published
- 2017
46. Summary comment to: 'Severe perioperative bleeding in renal cell carcinoma after elective pericardiocentesis associated left ventricular puncture: case report.'
- Author
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Javier D Lasala, Miguel Patino, and Gabriel E. Mena
- Subjects
medicine.medical_specialty ,business.industry ,Renal cell carcinoma ,Pericardiocentesis ,medicine.medical_treatment ,Anesthesia ,medicine ,Perioperative ,business ,Omics ,medicine.disease ,Surgery - Published
- 2017
47. Does anesthesia technique have an effect on patient reported outcomes (PROS) in patients on an enhanced recovery after surgery (ERAS) program?
- Author
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S. Wang, Pedro T. Ramirez, M. Iniesta-Donate, Javier Lasala, Gabriel E. Mena, Larissa A. Meyer, Qiuling Shi, Lori Williams, and S. Veum
- Subjects
Nutrition and Dietetics ,business.industry ,Endocrinology, Diabetes and Metabolism ,Anesthesia ,Medicine ,In patient ,business ,Enhanced recovery after surgery - Published
- 2019
48. Effect of anesthesia technique on intra-operative and post-operative morphine equivalent daily dose (MEDD) in open gynecologic surgery in an enhanced recovery after surgery (ERAS) pathway
- Author
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Juan P. Cata, B. Pitcher, Javier Lasala, Katherine E. Cain, M. Iniesta-Donate, Ashley Siverand, Gabriel E. Mena, Tina Suki, Pedro T. Ramirez, and Larissa A. Meyer
- Subjects
medicine.medical_specialty ,Nutrition and Dietetics ,Intra operative ,business.industry ,Endocrinology, Diabetes and Metabolism ,Anesthesia ,Morphine ,Medicine ,Post operative ,business ,Enhanced recovery after surgery ,Surgery ,medicine.drug - Published
- 2019
49. Platelet-to-Lymphocyte Ratio and Use of NSAIDs During the Perioperative Period as Prognostic Indicators in Patients With NSCLC Undergoing Surgery
- Author
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Reza J. Mehran, Gabriel E. Mena, Juan P. Cata, Vijaya Gottumukkala, David C. Rice, Brenda M. Lee, Lei Feng, Andrea Rodriguez, and Jun Yu
- Subjects
Blood Platelets ,Male ,medicine.medical_specialty ,Lung Neoplasms ,Lymphocyte ,Inflammation ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Carcinoma, Non-Small-Cell Lung ,Carcinoma ,medicine ,Humans ,In patient ,Platelet ,Lymphocytes ,Perioperative Period ,Aged ,Retrospective Studies ,business.industry ,Anti-Inflammatory Agents, Non-Steroidal ,Retrospective cohort study ,Hematology ,General Medicine ,Perioperative ,Middle Aged ,medicine.disease ,Prognosis ,Surgery ,medicine.anatomical_structure ,Oncology ,030220 oncology & carcinogenesis ,Female ,medicine.symptom ,business - Abstract
Background Hematological biomarkers of inflammation such as the neutrophil-to-lymphocytic rate have been reported as predictors of survival in a variety of cancers. The aim of the present study was to investigate the prognostic value of the perioperative platelet-to-lymphocyte ratio in patients with non–small-cell lung cancer (NSCLC) and to elucidate the effects of the perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) on tumor recurrence and survival in patients undergoing surgical resection for NSCLC. Methods This retrospective study included data from 1,637 patients who underwent surgical resection for stage I, II, or III NSCLC. Perioperative data and tumor-related variables were included. Univariate and multivariable Cox proportional hazard ratio (HR) models were used to evaluate the association between perioperative platelet-to-lymphocyte ratio and NSAID use on recurrence-free survival (RFS) and overall survival (OS). Results Multivariate analysis showed that a preoperative platelet-to-lymphocyte ratio of at least 180 was associated with reduced rates of RFS (HR = 1.22; 95% confidence interval [CI], 1.03–1.45; P = .019) and OS (HR = 1.33; 95% CI, 1.10–1.62; P = .004). Perioperative use of NSAIDs showed no statistically significant changes in RFS and OS rates (P = .72 and P = .44, respectively). Conclusions A higher preoperative inflammatory status is associated with decreased rates of RFS and OS in patients with NSCLC undergoing curative surgery. Perioperative use of NSAIDs was not found to be an independent predictor of survival.
- Published
- 2016
50. Preoperative Anemia, Blood Transfusion, and Neutrophil-to-Lymphocyte Ratio in Patients with Stage I Non–Small Cell Lung Cancer
- Author
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Fernando J. Martinez, Andrea Rodriguez-Restrepo, Reza J. Mehran, Lei Feng, Cristina Gutierrez, Joseph L. Nates, David C. Rice, Gabriel E. Mena, Vijaya Gottumukkala, and Juan P. Cata
- Subjects
medicine.medical_specialty ,Blood transfusion ,Anemia ,Proportional hazards model ,business.industry ,medicine.medical_treatment ,Hazard ratio ,General Medicine ,Perioperative ,030204 cardiovascular system & hematology ,medicine.disease ,Gastroenterology ,Article ,3. Good health ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,030220 oncology & carcinogenesis ,Internal medicine ,Propensity score matching ,medicine ,Stage (cooking) ,Neutrophil to lymphocyte ratio ,business - Abstract
Perioperative and postoperative blood transfusions (BT), anemia and inflammation are associated with poor survivals in patients with non-small cell lung cancer (NSCLC). This study investigated the impact of perioperative BT on the survival of patients with NSCLC taking into account their preoperative inflammatory status and the presence of anemia. Demographic, perioperative, and survival data for 861 patients with stage I NSCLC was collected retrospectively. The primary endpoints of interest were recurrence-free (RFS) and overall survival (OS). Before and after propensity score matching, univariate and multivariable Cox proportional hazards models were used to evaluate the association between covariates and survival. A neutrophil-to-lymphocyte ratio (NLR) < 5 (hazard ratio [HR]: 0.58, 95% CI: 0.38-0.87; p = 0.009) and normal Hb concentration (HR: 0.72, 95% CI: 0.72; p = 0.022) were independently associated with longer RFS. The administration of blood perioperatively was associated with a trend towards worse RFS (HR: 0.69, 95% CI: 0.47-1.02; p = 0.066). The multivariate analysis also revealed that an NLR < 5 (HR: 0.48, 95% CI: 0.3-0.76; p = 0.001) and the absence of BT (HR: 0.63, 95% CI: 0.4-0.98; p = 0.04) were significantly associated with lower mortality risk. The propensity score matching analysis did not confirm the association between BT and poor RFS (HR: 0.63, 95% CI: 0.35-1.1; p = 0.108) and OS (HR: 0.52, 95% CI: 0.26-1.04; p = 0.06). Inflammation and anemia are common finding in patients with stage 1 NSCLC. After adjusting for these two important confounders, this study confirms that previous reports demonstrating an association between BT and poor survival after NSCLC surgery.
- Published
- 2016
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