Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler Drive, Unit 1484, Houston, TX, 77030, USA.
Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Ann Surg Oncol. 2019 Mar;26(3):782-790. doi: 10.1245/s10434-018-07150-5. Epub 2019 Jan 9.
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.
Surgical cases performed from 2011 to 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.
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 < 0.0001), severe complication rates (7.4% vs. 10%, p = 0.010), and median hospital length of stay (4 vs. 5 days, p < 0.0001). There was no change in readmission rates (ER vs. TP, 8.6% vs. 9.0%, p = 0.701). Subanalyses of high magnitude cases and specialty-specific outcomes consistently demonstrated improved outcomes with ER protocol adherence, including decreased opioid use.
This assessment of a large-scale ER implementation in multispecialty major oncologic surgery indicates its feasibility, safety, and efficacy. Future efforts should be directed toward defining the long-term oncologic benefits of these protocols.
加速康复（ER）方案在外科实践中越来越多地被应用。然而，在结直肠外科之外，其在大型肿瘤外科中的可行性、安全性和疗效尚未得到证实。本研究比较了一家大型综合癌症中心多专科实施 ER 方案前后患者的结局。
回顾了 2011 年至 2016 年期间通过机构 NSQIP 数据库捕获的手术病例。排除门诊和急诊手术后，共有 2747 例病例纳入分析。根据术前患者教育和电子病历医嘱集驱动的阿片类药物节约性镇痛、目标导向液体治疗以及术后早期饮食进展和活动的 ER 依从性，将病例分为 ER 方案组和传统术后（TP）方案组。
约一半的患者接受 ER 方案治疗（46%），另一半接受传统术后方案治疗（54%）。ER 方案治疗与总并发症发生率降低相关（20% vs. 33%，p<0.0001）、严重并发症发生率降低（7.4% vs. 10%，p=0.010）和中位住院时间缩短（4 天 vs. 5 天，p<0.0001）。再入院率无变化（ER 组 vs. TP 组，8.6% vs. 9.0%，p=0.701）。高难度病例和专科特定结局的亚分析一致表明，ER 方案的依从性可改善结局，包括减少阿片类药物的使用。
本研究评估了多专科大型肿瘤外科中 ER 方案的广泛实施，表明其具有可行性、安全性和疗效。未来的努力应致力于确定这些方案的长期肿瘤学获益。
