2018 Vol. 9, No. 6

Guideline Interpretation
Abstract:
As Consensus on ERAS and Guidelines for the Pathway Management in China (2018) was published, China has taken an important step forward in promoting the enhanced recovery protocol. The interpretation of its anesthesia part has an important guidance for anesthesiologists to better understand clinical practice methods and the pathway of perioperative management. The interpretation made a deep evidence-based exploration in the anesthesia-related core parts from the guideline, aiming to further disclose the direction of the development of clinical practice of anesthesiology in the near future from the vision of perioperative medicine.
Abstract:
The concept and pathway of enhanced recovery after surgery (ERAS) have been widely accepted and proved to be beneficial in terms of improving postoperative outcomes in China. In 2018, experts from the Chinese Society of Surgery and the Chinese Society of Anaesthesia jointly organized and published the Consensus on ERAS and Guidelines for Pathway Management in China (2018) in both Chinese Journal of Practical Surgery and Chinese Journal of Anesthesiology at the same time. This consensus is incorporated with the latest literature and the experts' own clinical practice experience, and it marks a great progress of the ERAS practice in China. In this paper, we try to make an interpretation of the surgery part of the consensus, and the highlights and hot issues will be further discussed.
Abstract:
Enhanced recovery after surgery (ERAS) has been launched and implemented in gastrointestinal (GI) surgery for more than 20 years, especially in colorectal surgery. And several ERAS guidelines for GI surgery have been published. Recently, the ERAS guidelines for improving the standardization of perioperative management of GI surgery have been revised and updated several times in China and abroad. Clinical nutrition, which includes preoperative nutritional risk assessment, pre-rehabilitation such as oral nutritional supplement, and early postoperative enteral nutrition, is an indispensable and important component of ERAS and has been paid more attention. Here we mainly summarized the clinical nutrition part of the updated ERAS guides in GI surgery.
Specialist Forum
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The concept of enhanced recovery after surgery (ERAS) is to optimize a series of perioperative measures to relieve surgical stress, reduce postoperative complications, shorten hospital stays, and finally accelerate the recovery. Gastroenterology is still the most studied and most successful field in the present research status of ERAS. However, many improperly implemented strategies of ERAS, like unresolved preoperative malnutrition, long fasting, perioperative hypervolemia, and overuse of opioid analgesics, could all damage the gastrointestinal function, and the impaired gastrointestinal function could impede the progress of ERAS by increasing postoperative complications and delaying hospital stays. Thus, it is critical to standardize the strategies of anesthesia and perioperative ERAS related to the gastrointestinal function in order to improve patient outcomes.
Abstract:
Enhanced recovery after surgery (ERAS) refers to a series of perioperatively optimized interventions based on evidence-based medicine, to reduce surgical stress and accelerate postoperative recovery of patients. The basic principles of ERAS include preoperative counseling, elimination of routine bowel preparation, preoperative carbohydrate uploading, multimodal analgesia, intraoperative temperature monitoring, optimized fluid infusion, avoidance of drainage placement, early postoperative feeding and ambulation. Studies have shown that ERAS can significantly shorten the length of hospital stay, reduce perioperative complications, save hospitalization expenditure, improve the patient's life quality, and may benefit patients in the long term. The successful implementation of ERAS requires combined efforts of multiple disciplines to develop a standard protocol for clinical practitioners, while the actual situation of each medical center and the specific condition of each patient should be fully investigated to achieve individualization and optimization at the same time.
Abstract:
Laparoendoscopic single site surgery has been used in gynecology for 50 years, and has been popularized in China in recent years. There is no doubt about its safety and effectiveness. Nevertheless, the evaluation of single-port laparoscopy focuses more on surgical techniques, bleeding, cosmetic satisfaction, score of pain, prevention of complications, and the long-term prognosis of cancer patients, but the postoperative rehabilitation efficacy of patients is seldom concerned. Ambulatory laparoendoscopic single site surgery guided by the theory of enhanced recovery after surgery for benign gynecological diseases can maximize the advantages of single-port laparoscopy, significantly reduce the patients' hospital stays and hospitalization expenses, and the benefit of patients can be maximized.
Guidelines and Consensuses
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This guideline has been announced by experts of Menopause Group, Obstetrics and Gynecology Branch, Chinese Medical Association on menopause management and menopause hormone therapy (MHT) to help healthcare professionals in optimizing their management of transitionally menopausal and postmenopausal women. New results on MHT and menopause management after 2012 as well as all of the important information from main international guidelines were reviewed. Levels of evidence and grades of recommendations were also included. The standardized MHT flowcharts of diagnosis and treatment were retained and improved from the last version. The menopause staging system, Stages of Reproductive Aging Workshop +10 (STRAW+10), was added to facilitate the understanding on clinical, biological, and endocrine changes in the reproductive aging process for doctors in this field. Vasomotor symptoms (VMS), genitourinary syndrome of menopause, and prevention ofmenopause-related low bone mass and osteoporosis were reconfirmed as the indications for MHT. The risks of MHT depend on types, dosages, time of use, management, start-up time, and whether progesterone is used. To maximize the benefits and minimize the risks, MHT should be individualized based on the updated evidence, and the benefit-risk ratio should be reassessed annually. For women within 10 years after menopause, or younger than 60 years old with no contraindications, MHT for the treatment of VMS and prevention of bone loss and fractures has the most favorable benefit-risk ratio. Premature ovarian insufficiency patients should be treated with hormone replacement therapy till the average age of natural menopause and followed by the postmenopausal MHT.
Original Contributions
Abstract:
  Objective  The aim of this study was to evaluate the safety and efficacy of enhanced recovery after surgery (ERAS) program focusing on the concept of integrative clinical nutrition for the gastrointestinal surgery.  Methods  This study was a prospective single-center cohort study. Patients who underwent gastrointestinal surgery in the Department of General Surgery of Peking Union Medical College Hospital from December 2015 to April 2018 were continuously enrolled in the study. Patients who were treated by the professional team of gastrointestinal and nutritional metabolism and received ERAS management were assigned to the ERAS group, and patients who were treated by the other professional teams and received traditional perioperative management were assigned to the control group. The ERAS program included especially focusing on the preoperative nutritional assessment, nutritional supplements by oral or tube feeding, early postoperative enteral nutrition, combination with other series of ERAS items including minimally invasive surgery, multimodal analgesia, non-steroidal antiinflammatory drugs as major postoperative analgesic meditation, and so on. The control group was under traditional perioperative management including open or minimally invasive surgery, general anesthesia, opioid analgesia, and so on. The primary outcome was the postoperative length of stay, the secondary outcomes included total hospitalization cost, the incidence of postoperative complications, and readmission rate within postoperative 60 days.  Results  Two hundred and four patients undergoing gastrointestinal surgery were enrolled, 102 patients in the ERAS group and the other 102 in the control group. The postoperative length of stay in the ERAS group was significantly shorter than that in the control group[(7.2±4.5)days vs. (9.8±4.8)days, P < 0.001] and total hospitalization cost in the ERAS group was significantly lower than that in the control group[(41 125±18 593)Yuan vs. (51 512±19 453)Yuan, P < 0.001] as well. There was no significant difference in the incidence of postoperative complications (Clavien-Dindo classification ≥ grade Ⅱ, ERAS group 9.8% vs. control group 13.7%, P=0.646) and readmission rate within postoperative 60 days (ERAS group 2.9% vs. control group 2.0%, P=1.000) between the two groups.  Conclusion  Perioperative nutrition-focused ERAS programs are safe and effective for the gastrointestinal surgery and might enhance the recovery after surgery.
Abstract:
  Objective   The aim of this study was to explore the safety and effectiveness of enhanced recovery after surgery (ERAS) in perioperative management of pancreaticoduodenectomy.   Methods   Among the patients undergoing pancreaticoduodenectomy from April 2016 to April 2018 in the Department of General Surgery of Peking Union Medical College Hospital, 63 patients who met the inclusion and exclusion criteria were enrolled in ERAS group and the other 60 patients in the control group. The perioperative parameters, postoperative complications, and clinical outcomes were compared between the two groups.   Results   There was no difference between the ERAS group and the control group in baseline data. The operative approach of the ERAS group was mainly laparoscopicsurgery and that of the control group was mainly open surgery (P < 0.01). The operation time in ERAS group was longer than that in control group (P < 0.01) while the intraoperative blood loss was significantly reduced (P < 0.01). Compared with the control group, the ERAS group had the shorter time of gastric tube removal, earlier postoperative fluid intake, shorter postoperative hospital stay, and significantly less hospitalization expenses (all P < 0.05). The incidence of delayed gastric emptying of the ERAS group was significantly lower than that of the control group (3.2% vs. 13.3%, P < 0.05). There was no significant difference in the incidence of total complications, pancreatic fistula, biliary fistula, postoperative hemorrhage, secondary hospital admission, secondary surgery, and death between the two groups. In the ERAS group, the intraoperative blood loss (P < 0.01), postoperative hospital stays (P < 0.05), and the hospitalization expenses (P < 0.05) of the laparoscopic subgroup were significantly lower than those of the open subgroup.   Conclusion   ERAS is safe and effective for the perioperative management of pancreaticoduodenectomy, which can significantly accelerate the recovery of patients without increasing the risk of complications.
Abstract:
  Objective   This study aimed to evaluate the safety and effectiveness of different anesthetic approaches and multimodal analgesia in enhanced recovery after surgery (ERAS) when applied to open pancreaticoduodenectomy patients.   Methods   In this retrospective cohort study, we consecutively collected clinical data from 39 patients undergoing open pancreaticoduodenectomy in Peking Union Medical College Hospital from March 2016 to April 2018, among which 19 patients received ERAS strategy (ERAS group) and 20 traditional strategy (control group), and compared the differences in intra-operative hemodynamic changes, post-operative rehabilitation, length of stay, and costs between the ERAS group and the control group.   Results   The intraoperative opioid consumption and postoperative lactic acid in the ERAS group were lower than those in the control group (both P < 0.05). White blood cell and neutrophil counts on the postoperative day 1, blood glucose, pain score, postoperative nausea and vomiting, postoperative analgesia satisfaction, time to remove the transurethral catheter and nasogastric tube, time to exhaust and ambulation, and medical costs were all improved compared to the control group (all P < 0.05). Whereas operating duration, intraoperative hemodynamic changes, and intraoperative bleeding were comparable between the two groups (all P>0.05).   Conclusion   Different perioperative anesthesia plans and multimodal analgesia in ERAS strategy are safe when applied to open pancreaticoduodenectomy patients. It could effectively mitigate operative stress, decrease opioid exposure, expedite postoperative rehabilitation, shorten the length of hospital stay, and decrease medical cost.
2018, 9(6): 546-549. doi: 10.3969/j.issn.1674-9081.2018.06.011
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2018, 9(6): 574-576. doi: 10.3969/j.issn.1674-9081.2018.06.017
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Review
Abstract:
Goal-directed fluid therapy (GDT), as an important part of enhanced recovery after surgery (ERAS), is of great concern in accelerating the recovery and improving the prognosis after major surgery. Based on existing reports, we summarized some monitoring methods, observation indexes, and liquid selections commonly used in clinical practice, and discussed the application and effects of GDT of ERAS in gastrointestinal surgery, thoracic surgery, liver surgery, head and neck carcinoma surgery. The result showed that GDT had significant advantages for fluid management in major surgery, including decreasing overall complication rate, reducing hospital stays, accelerating recovery, and improving prognosis.
Clinical Biobank
Abstract:
China is a country with a large population, rich resources and conspicuous environmental heterogeneity. The 56 nationalities of China boast great varieties in physiques, physiological data, hereditary phenotype, and genotype. Therefore, they are ideal resources for researches on endemic diseases, family disease genealogy, population migration, and genetic anthropology. However, due to the discrepancy in areas such as cultural custom, knowledge background, and ethical religion, the sample collection of human genetic resources and signing of informed consent are facing great challenges. This paper focused on the questions concerning the signing of informed consent that we should pay attention to during the sample collection of human genetic resources in the areas inhabited by minority nationalities, and expounded ten questions including "mode choice of informed consent", "procedures of informed consent in ethnic minorities", "informed consent should fully embody the characteristics and taboos of ethnic culture", hopefully, to provide references for researchers in this field.Researchers should abide by related procedures of administration management in accordance with ethical principles, respect cultural customs and ethnic religions of ethnic minority groups, and thereby make sure to complete the informed consent during sample collection of human genetic resources in ethnic minority groups in China.
Guidelines Express
Abstract:
"Management of malignant pleural effusions (MPE)", an official clinical practice guideline approved by the American Thoracic Society, the Society of Thoracic Surgeons, and the Society of Thoracic Radiology, was published in the American Journal of Respiratory and Critical Care Medicine on October 1st, 2018. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach and the PICO (Population, Intervention, Comparator, and Outcomes) format, a multidisciplinary panel raised and answered seven questions on the clinical management of MPE. The relevant evidences were summarized and recommendations were developed for clinical practice. Based on the available evidence, the panel made the following recommendations:(1)ultrasound imaging should be used to guide pleural interventions in patients with known or suspected MPE; (2)therapeutic pleural interventions should not be performed in asymptomatic patients with known or suspected MPE; (3)either an indwelling pleural catheter (IPC) or chemical pleurodesis can be used in symptomatic patients with MPE and suspected expandable lung; (4)large-volume thoracentesis can be conducted to assess symptomatic response and lung expansion; (5)the use of either talc poudrage or talc slurry can be considered in patients with symptomatic MPE and expandable lung; (6)IPC should be used instead of pleurodesis in patients with nonexpandable lung or failed pleurodesis; and (7)antibiotics should be used in IPC-associated infections and there is no need to removed the catheter.
History of Medicine
Abstract:
In the 1940s, Wu Ying-kai and Harold H. Loucks set up a multi-branch cooperation group on esophageal cancer in Peking Union Medical College Hospital and the earliest exploration of surgical treatment for esophageal cancer was carried out in China.This paper reviewed the experience and historical significance of the first operation of esophageal cancer resection and reconstruction in China and summarized the experience of Wu Ying-kai and Harold H.Loucks on perioperative management of esophageal cancer surgery and optimization of the esophageal anastomosis.