Publications by authors named "Gabriele Baldini"

32 Publications

Implication of a novel postoperative recovery protocol to increase day 1 discharge rate after anatomic lung resection.

J Thorac Dis 2021 Nov;13(11):6399-6408

Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.

Background: Chest-tube drainage and prolonged air leak after anatomic lung resection (ALR) continue to drive admission days for most programs employing minimal access techniques. The aim of the study was to evaluate the impact of a novel postoperative recovery protocol with revised chest tube management strategies to target discharge on post-operative day 1 (POD1) after ALR.

Methods: This is a pilot study investigating a novel enhanced recovery protocol which either allowed chest tube removal on POD1 or ambulatory management with indwelling chest tube using a portable closed drainage system. We included all patients undergoing video-assisted thoracoscopic surgery (VATS)-ALR; exclusion criteria were open surgery, non-anatomic or extended resections.

Results: A total of 139 patients were included in the study [N=29 portable drainage (PD), N=110 standard pathway (SP)]. POD1 discharge rate was 72% in PD 15% in SP cohort (P<0.001). Median length of stay (LOS) was 1 day [interquartile range (IQR), 1-2 days] in PD cohort, while it was 3 days (IQR, 2-5 days) in SP cohort (P<0.001). There were no significant differences in length of indwelling chest-tube, rate of discharge with chest-tube, post-operative complications, or readmissions. On multivariate analysis, PD pathway as well as short surgical time were significant predictors of discharge on POD1.

Conclusions: Our results indicate that POD1 discharge rates of 72% after VATS-ALR can be safely achieved by a well-developed perioperative care pathway and simple chest tube drainage interventions. Based on these findings we are currently drafting a follow-up study to investigate the possibility of performing ALRs as day surgery.
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http://dx.doi.org/10.21037/jtd-21-965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8662496PMC
November 2021

Trajectory of gastrointestinal function after laparoscopic colorectal surgery within an enhanced recovery pathway.

Surgery 2021 Nov 26. Epub 2021 Nov 26.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC; Colon and Rectal Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC. Electronic address:

Background: Early identification of colorectal surgery patients predicted to have uneventful gastrointestinal recovery may allow for early discharge. Our objective was to identify trajectories of gastrointestinal recovery within a colorectal surgery enhanced recovery pathway.

Methods: Data from 2 prospective studies enrolling adult patients undergoing elective laparoscopic colorectal resection at a specialist colorectal referral center were analyzed (2013-2019). All patients were managed according to a mature enhanced recovery pathway with a 3-day target length of stay. Postoperative gastrointestinal symptoms were collected daily and expressed using the validated I-FEED score. Latent-class growth curve (trajectory) analysis was used to identify different I-FEED trajectories over the first 3 postoperative days.

Results: A total of 192 patients were analyzed. Trajectory analysis identified 3 distinct trajectories: trajectory 1 had no gastrointestinal symptoms (41%); trajectory 2 had mild early symptoms with improvement over time (48%); and trajectory 3 had gastrointestinal symptoms that significantly worsened between postoperative days 1 and 2 (11%). I-FEED score ≤1 on postoperative day 1 predicted trajectory 1. Trajectory 1 had the best clinical outcomes, whereas trajectory 3 had the worst.

Conclusion: I-FEED trajectory over postoperative days 1-3 was associated with clinical outcomes and may be used to predict gastrointestinal recovery. Findings from this study may inform clinical decision making regarding early hospital discharge within colorectal enhanced recovery pathways.
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http://dx.doi.org/10.1016/j.surg.2021.08.062DOI Listing
November 2021

Functional capacity of prediabetic patients: effect of multimodal prehabilitation in patients undergoing colorectal cancer resection.

Acta Oncol 2021 Aug 8;60(8):1025-1031. Epub 2021 Jun 8.

Department of Anesthesia, McGill University, Montreal, Canada.

Background: Prehabilitation is the process of increasing functional capacity (FC) before surgery. Poor glycemic control is associated with worse outcomes in patients undergoing surgery. Therefore, prediabetic patients could particularly benefit from prehabilitation.

Methods: This is a pooled analysis of individual patient data from three multimodal prehabilitation trials in colorectal cancer surgery. Following a baseline assessment using the 6-minute walking test (6MWT), subjects were randomized to multimodal prehabilitation or to a control group. Participants were reassessed 24 h before surgery and 4 weeks after surgery. Prediabetes (PreDM) was defined as HbA1c 5.7%-6.4%. Multivariable logistic regression was used to adjust for potentially confounding variables.

Results: Participation in a prehabilitation program was the most important predictive factor of clinical improvement in FC prior to surgery (Adjusted OR 2.42, 95% CI 1.18, 4.94); prediabetes was not a statistically significant predictor of improvement in FC after adjustments for covariates. Prehabilitation attenuated the loss of FC in unadjusted analyses after surgery in prediabetic patients (PreDM Control: median change -6 m [IQR -50-20] vs PreDM Prehab: median change +25 m [IQR -20-53],  = 0.045). Adjusted analyses also suggested the protective effect against loss of FC after surgery was stronger in prediabetic patients (PreDM Prehab vs PreDM Control: OR 5.5, 95% CI: 1.2-25.8; Normo Prehab vs Normo Control: OR 1.5, 95% CI: 0.53-4.52).

Conclusions: Multimodal prehabilitation favored clinical recovery of FC after surgery in CRC patients, especially prediabetic patients.
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http://dx.doi.org/10.1080/0284186X.2021.1937307DOI Listing
August 2021

Enhanced Recovery 2.0 - Same Day Discharge With Mobile App Follow-Up After Minimally Invasive Colorectal Surgery.

Ann Surg 2021 Jun 2. Epub 2021 Jun 2.

Department of Surgery, McGill University Health Centre, Montreal, QC, Canada Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada Department of Anaesthesia, McGill University Health Centre, Montreal, QC, Canada.

Summary Background Data: Discharge prior to gastrointestinal recovery and use of mobile health technology for remote follow-up may allow for same-day discharge (SDD) after minimally-invasive colectomy within an Enhanced Recovery Pathway (ERP).

Objective: To investigate the feasibility of SDD protocol with post-discharge follow-up using a mobile phone app in patients undergoing elective minimally-invasive colectomy.

Methods: Adult patients undergoing elective laparoscopic colectomy or loop ileostomy reversal from 02/2020-11/2020 were screened for eligibility. Patients were eligible if they lived within a 30-minute drive from the hospital, had an adequate support system at home, and owned a smart phone. Patients were discharged from the recovery room on the day of surgery based on set criteria with post-discharge remote follow-up using a mobile application. Feasibility was defined as discharge on the day of surgery without ED visit or readmission within the first 3 days. 30-day complications, ED visits, and readmissions were compared to a non-SDD historical cohort (05/2019-03/2020) also remotely followed-up using the same mobile phone app (standard ERP group).

Results: A total of 48 patients were recruited to SDD, of which 77% were discharged on the day of surgery without subsequent ED visit in the first 72 hours. There were 11 patients that could not be discharged, including 7 for failure of discharge criteria and 4 for intra-operative complications/concerns. Overall 30-day complications in the SDD group (17%) was similar to the standard ERP group (15%, p=0.813). ED visits (SDD10% vs. standard ERP8%, p=0.664) and readmissions (6% vs. 4%, p=0.681) were also similar.

Conclusions And Relevance: Findings from this study support the feasibility of a SDD protocol in select patients undergoing minimally-invasive colorectal resection. SDD colectomy protocols may represent the next evolution of ERP and postoperative recovery.
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http://dx.doi.org/10.1097/SLA.0000000000004962DOI Listing
June 2021

Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care.

J Cardiothorac Vasc Anesth 2021 11 23;35(11):3255-3264. Epub 2021 Feb 23.

Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada.

Objective: To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy.

Design: Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery.

Setting: Single center, tertiary university hospital.

Participants: Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned.

Interventions: At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs.

Measurements And Main Results: Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101).

Conclusions: A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.
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http://dx.doi.org/10.1053/j.jvca.2021.02.049DOI Listing
November 2021

The association of alvimopan treatment with postoperative outcomes after abdominal surgery: A systematic review across different surgical procedures and contexts of perioperative care.

Surgery 2021 04 27;169(4):934-944. Epub 2020 Dec 27.

Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada. Electronic address:

Background: Alvimopan is a Food and Drug Administration-approved treatment to accelerate gastrointestinal recovery after abdominal surgery; however, benefits may vary across different procedures and contexts of care. The purpose of this study is to summarize the evidence regarding the effect of alvimopan on postoperative outcomes after abdominal surgery.

Methods: Major databases (Medline, Embase, Biosis, Cochrane, Web of Science, and Scopus) were searched for randomized controlled trials and nonrandomized studies comparing alvimopan versus control. Risk of bias was assessed using Cochrane's risk of bias tool 2.0 (for randomized controlled trials) and Risk of Bias in Nonrandomized Studies-of Intervention tool (for nonrandomized studies). Results were appraised descriptively as heterogeneity in reporting and risk of bias hindered meta-analysis. Quality of evidence across different surgical procedures and contexts of care (ie, open versus minimally invasive surgery, traditional care versus enhanced recovery pathway) was evaluated using Grading of Recommendations Assessment, Development, and Evaluation.

Results: Nine randomized controlled trials and 35 nonrandomized studies were identified. Evidence of low to moderate certainty supports that alvimopan reduces length of stay and improves gastrointestinal recovery after open bowel resection and open radical cystectomy. Limited evidence supports alvimopan for surgeries not listed in Food and Drug Administration labels (ie, total abdominal hysterectomy and retroperitoneal lymph node dissection). Similar effects were observed in traditional and enhanced recovery pathway settings, but enhanced recovery pathway elements varied across studies. There is very low certainty of evidence supporting alvimopan for patients undergoing minimally invasive surgery.

Conclusion: Evidence supports that alvimopan improves outcomes after open bowel resection and open radical cystectomy. Benefits for patients undergoing minimally invasive surgery and treated in contemporary enhanced recovery pathway settings remain uncertain. These findings contribute important new knowledge to inform evidence-based alvimopan prescribing.
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http://dx.doi.org/10.1016/j.surg.2020.11.025DOI Listing
April 2021

Redesigning the Preoperative Clinic: From Risk Stratification to Risk Modification.

JAMA Surg 2021 02;156(2):191-192

Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1001/jamasurg.2020.5550DOI Listing
February 2021

From preoperative assessment to preoperative optimization of frail older patiens.

Eur J Surg Oncol 2021 03 17;47(3 Pt A):519-523. Epub 2020 Jun 17.

Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada.

Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.
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http://dx.doi.org/10.1016/j.ejso.2020.06.011DOI Listing
March 2021

Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis.

BMJ Open 2020 02 2;10(1):e035443. Epub 2020 Feb 2.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada

Introduction: Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery.

Methods And Analysis: Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system.

Ethics And Dissemination: Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.
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http://dx.doi.org/10.1136/bmjopen-2019-035443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045253PMC
February 2020

Development of a clinical pathway for enhanced recovery in colorectal surgery: a Canadian collaboration

Can J Surg 2020 01 16;63(1):E19-E20. Epub 2020 Jan 16.

Mary-Anne Aarts, MD; Biniam Kidane, MD, MSc; Liane Feldman, MDCM; Magda Recsky, MD, MSc; Tony MacLean, MD; Evan Minty, MC, MSc; Stuart McCluskey, MD, PhD; Kelly Mayson, MD; Selena Fitzgerald, BScN, RN; Lucie Filteau, MD; Hance Clark, MD, PhD; Naveen Eipe, MBBS, MD; Gabrielle Page, PhD; Krista Brecht, RN, BScN; Veronique Brulotte, MD, MSc; Husein Moloo, MD, MSc; Heather Keller, RD, PhD; Manon Laporte, RD; Marlis Atkins, RD; Chelsia Gillis, RD, MSc; Louis-Francois Cote, RD; Celena Scheede Bergdahl, MSc, PhD; Julio Fiore, PT, MSc, PhD; Jackie Farquhar, MD; Chiara Singh, BScPT; Sender Liberman, MD; Amal Bessissow, MD, MSc; Bevin Ledrew; Nancy Posel, PhD; Kathy Kovacs Burns, MSc, MHSA, PhD; Valerie Phillips; Jennifer Rees, BSc.

Summary: Enhanced Recovery After Surgery (ERAS) is a model of care that was introduced in the late 1990s by a group of surgeons in Europe. The model consists of a number of evidence-based principles that support better outcomes for surgical patients, including improved patient experience, reduced length of stay in hospital, decreased complication rates and fewer hospital readmissions. A number of Canadian surgical care teams have already adopted ERAS principles and have reported positive outcomes. Arising from the Canadian Patient Safety Institute’s Integrated Patient Safety Action Plan for Surgical Care Safety, and with support from numerous partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. We discuss the development of a multidisciplinary clinical pathway for elective colorectal surgery to help guide Canadian clinicians.
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http://dx.doi.org/10.1503/cjs.006819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828945PMC
January 2020

Preventing opioid prescription after major surgery: a scoping review of opioid-free analgesia.

Br J Anaesth 2019 11 25;123(5):627-636. Epub 2019 Sep 25.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Department of Surgery, McGill University, Canada McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Canada McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.

Background: Excessive opioid prescribing after surgery has been recognised as a contributor to the current crisis of opioid addiction and overdose. Clinicians may potentially tackle this crisis by using opioid-free postoperative analgesia; however, the scientific literature addressing this approach is sparse and heterogeneous, thereby limiting robust conclusions. A scoping review was conducted to systematically map the extent, range, and nature of the literature addressing postoperative opioid-free analgesia.

Methods: Eight bibliographic databases were searched for studies addressing opioid-free analgesia after a major surgery. We extracted the study characteristics, including design, country, year, surgical procedure(s), and interventions. Results were organised thematically according to surgical specialty and targeted phase of recovery: in hospital (early recovery, ≤24 h after operation; intermediate recovery, >24 h) and post-discharge (late recovery). Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for scoping reviews.

Results: We identified 424 studies addressing postoperative opioid-free analgesia. The number of studies conducted in countries where the opioid crisis is primarily focused was remarkably low (USA, n=11 [3%]; Canada, n=5 [1%]). Many RCTs compared opioid-free vs opioid analgesia during hospital stay (n=117), but few targeted analgesia post-discharge (n=8). Studies were predominantly focused on procedures in orthopaedic, general, and gynaecological/obstetric surgery. Limited attention has been directed towards non-pharmacological pain interventions. We did not identify knowledge synthesis studies (i.e. systematic reviews and meta-analyses) focused on the comparative effectiveness of opioid-free vs opioid analgesia.

Conclusions: Opioids remain a mainstay analgesic for managing pain after surgery, but alternative analgesia strategies should not be overlooked. This scoping review indicates numerous opportunities for future research targeting opioid-free postoperative analgesia. REVIEW REGISTRATION: http://www.researchregistry.com; ID: reviewregistry576.
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http://dx.doi.org/10.1016/j.bja.2019.08.014DOI Listing
November 2019

Validity of the I-FEED score for postoperative gastrointestinal function in patients undergoing colorectal surgery.

Surg Endosc 2020 05 30;34(5):2219-2226. Epub 2019 Jul 30.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.

Background: Postoperative ileus (POI) is common after gastrointestinal surgery and is associated with significant morbidity and costs. However, POI is poorly defined. The I-FEED score is a novel outcome measure for POI, developed by expert consensus. It contains five elements (intake, response to nausea treatment, emesis, exam, and duration, each scored with 0, 1, or 3 points) and classifies patients into normal, postoperative gastrointestinal intolerance (POGI), and postoperative gastrointestinal dysfunction (POGD). However, it has not yet been validated in a clinical context. The objective was to provide validity evidence for the I-FEED score to measure the construct of POI in patients undergoing colorectal surgery.

Methods: Data previously collected from a clinical trial investigating the impact of different perioperative fluid management strategies on primary POI in patients undergoing elective laparoscopic colectomy (2013-2015) were analyzed. Patients were managed by a longstanding Enhanced Recovery program (expected length of stay (LOS): 3 days). Daily I-FEED scores were generated (normal 0-2, POGI 3-5, POGD 6+ points) up to hospital discharge or postoperative day 7. Validity was assessed by testing the hypotheses that I-FEED score was higher (1) in patients with longer time to GI3 (tolerating diet + flatus/bowel movement), (2) with longer LOS (> 3 days vs shorter), (3) in patients with complications vs without, (4) in patients with poorer recovery (measured by Quality of Recovery-9 questionnaire).

Results: A total of 128 patients were included for analysis (mean age 61.7 years (SD 15.2), 57% male, 71% malignancy, and 39.1% rectal resection). Median LOS was 4 days [IQR3-5], and 32% experienced postoperative in-hospital morbidity. Overall, 48% of patients were categorized as normal, 22% POGI, and 30% POGD. The data supported all 4 hypotheses.

Conclusions: This study contributes preliminary validity evidence for the I-FEED score as a measure for POI after colorectal surgery.
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http://dx.doi.org/10.1007/s00464-019-07011-6DOI Listing
May 2020

Impact of persistent β-lactam allergy documentation despite delabeling in the perioperative setting.

J Allergy Clin Immunol Pract 2020 01 8;8(1):411-412. Epub 2019 Jul 8.

Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, Division of Experimental Medicine, McGill University, Montreal, QC, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2019.06.029DOI Listing
January 2020

Reply to: Perioperative use of cefazolin without preliminary skin testing in patients with reported penicillin allergy.

Surgery 2019 02 20;165(2):486-496. Epub 2018 Nov 20.

Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; The Research Institute of the McGill University Health Centre, Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.surg.2018.10.021DOI Listing
February 2019

The long-term prognostic impact of sentinel lymph node biopsy in patients with primary cutaneous melanoma: a prospective study with 10-year follow-up.

Ann Surg Treat Res 2018 Nov 25;95(5):286-296. Epub 2018 Oct 25.

Department of Surgery and Department of Morphology, Surgery and Experimental Medicine, S. Anna University Hospital and University of Ferrara, Ferrara, Italy.

Purpose: Sentinel lymph node (SLN) biopsy (SLNB) is widely accepted for staging of melanoma patients. It has been shown that clinico-pathological features such as Breslow thickness, ulceration, age, and sex are better predictors of relapse and survival than SLN status alone. The aims of this study were to evaluate the long-term (10-year) prognostic impact of SLNB and to determine predictive factors associated with SLN metastasis, relapse, and melanoma specific mortality (MSM).

Methods: This was a prospective observational study on 289 consecutive patients with primary cutaneous melanoma who underwent SLNB from January 2000 to December 2007, and followed until January 2014, at an Italian academic hospital.

Results: SLN was positive in 64 patients (22.1%). The median follow-up was 116 months (79-147 months). Ten-year disease-free survival and melanoma specific survival were poor in patients with positive SLN (58.7% and 66.4%, respectively). Only the increasing Breslow thickness resulted independently associated to an increased risk of SLN metastasis. Cox regression analysis showed that a Breslow thickness >2 mm was an independent predictor of relapse, and male sex and Breslow thickness >2 mm was a predictor of MSM. At 10 years, SLN metastasis was not significantly associated to either relapse or MSM.

Conclusion: After the fifth year of follow-up, SLN metastasis is not an independent predictive factor of relapse or mortality which are mainly influenced by the characteristics of the primary tumor and of the patient. Patients with a Breslow thickness >2 mm regardless of the SLN status should be considered at high risk for 10-year relapse and mortality.
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http://dx.doi.org/10.4174/astr.2018.95.5.286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204324PMC
November 2018

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation.

Surg Clin North Am 2018 Dec 24;98(6):1149-1169. Epub 2018 Aug 24.

Department of Anesthesia, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Québec H3G 1A4, Canada. Electronic address:

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.
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http://dx.doi.org/10.1016/j.suc.2018.07.004DOI Listing
December 2018

Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway.

Surg Endosc 2019 07 17;33(7):2313-2322. Epub 2018 Oct 17.

Department of Surgery, McGill University Health Centre, Montreal, Canada.

Background: Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery.

Methods: We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4 days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50-75%), positive evidence (75-95%), strong evidence (95-99%), and very strong evidence (> 99%).

Results: There were 323 patients analyzed (mean age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48 h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3 ml/kg/h for laparoscopic and 5 ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI.

Conclusions: The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.
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http://dx.doi.org/10.1007/s00464-018-6514-4DOI Listing
July 2019

De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis.

Surgery 2018 May 8. Epub 2018 May 8.

Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada. Electronic address:

Background: Suspected penicillin allergic individuals receive suboptimal non-β-lactams for intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if β-lactam de-labeling optimized choice of prophylactic antibiotics and improved intraoperative time efficiency.

Methods: A multistep approach was used. It included a risk assessment tool by an allergist, β-lactam skin testing and oral provocation. To determine the value of de-labeling, we appraised intraoperative antibiotic choices and correlated them with time to first incision.

Results: A total of 194 patients were evaluated preoperatively. Four patients were diagnosed β-lactam allergic on skin testing. Of the remaining 190 skin test negative patients, 146 were β-lactam challenged. Only 5% reacted and were considered β-lactam allergic. Cefazolin became the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed β-lactam allergic patients received intraoperative vancomycin. Patients avoiding use of vancomycin saved an average of 22 minutes in operative time. Of the 44 patients not having a β-lactam challenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin.

Conclusion: Using this three step process, almost all of those claiming penicillin allergy were de-labeled. In most patients that were drug challenged, β-lactam antibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a β-lactam. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach.
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http://dx.doi.org/10.1016/j.surg.2018.03.004DOI Listing
May 2018

In Reply.

Anesthesiology 2018 03;128(3):683-685

Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada (G.B.).

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http://dx.doi.org/10.1097/ALN.0000000000002051DOI Listing
March 2018

Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.

Dis Colon Rectum 2017 Aug;60(8):761-784

1 Department of Surgery, University of California, Irvine School of Medicine, Irvine, California 2 Department of Surgery, Baylor University Medical Center, Dallas, Texas 3 Department of Anesthesiology, McGill University, Montreal, Quebec, Canada 4 Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 5 Department of Colorectal Surgery, Cleveland Clinic Florida, Westin, Florida 6 Department of Surgery, McGill University, Montreal, Quebec, Canada 7 Norwalk Hospital, Western Connecticut Medical Group, Norwalk, Connecticut 8 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000000883DOI Listing
August 2017

Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial.

Anesthesiology 2017 07;127(1):36-49

From the Department of Anesthesia (J.C.G.-I., A.T., D.M., F.C., G.B.), Department of Surgery (B.L.S., A.S.L., P.C., N.P., L.S.F.), and Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery (N.P., L.S.F.), McGill University Health Centre, Montreal, Quebec, Canada.

Background: Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program.

Methods: Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome.

Results: One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different.

Conclusions: Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.
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http://dx.doi.org/10.1097/ALN.0000000000001663DOI Listing
July 2017

Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program.

Surg Endosc 2017 04 18;31(4):1760-1771. Epub 2016 Aug 18.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L9.309, Montreal, QC, H3G 1A4, Canada.

Introduction: Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection.

Methods: Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0-100). Regression analyses were adjusted for potential confounders.

Results: A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3-7). Patients were adherent to median 18 (IQR 16-20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0-22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p < 0.001), LOS (11 % reduction for every additional element, p < 0.001), 30-day postoperative morbidity (OR 0.78, p < 0.001), and the CCI (17 % reduction, p < 0.001). Laparoscopy (OR 4.32, p < 0.001), early mobilization out of bed (OR 2.25, p = 0.021), and early termination of IV fluid infusion (OR 2.00, p = 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity.

Conclusions: Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.
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http://dx.doi.org/10.1007/s00464-016-5169-2DOI Listing
April 2017

Anesthesia for colorectal surgery.

Anesthesiol Clin 2015 Mar;33(1):93-123

Royal Surrey County Hospital, Postgraduate School, University of Surrey, Guildford GU2 7XX, UK.

Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.
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http://dx.doi.org/10.1016/j.anclin.2014.11.007DOI Listing
March 2015

Optimal analgesia during major open and laparoscopic abdominal surgery.

Anesthesiol Clin 2015 Mar 9;33(1):65-78. Epub 2015 Jan 9.

Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada.

Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72 hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.
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http://dx.doi.org/10.1016/j.anclin.2014.11.005DOI Listing
March 2015

Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations.

Clin Nutr 2013 Dec 17;32(6):879-87. Epub 2013 Oct 17.

Dept of Urology, University Hospital of Lausanne, Switzerland.

Purpose: Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery.

Objectives: The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group.

Evidence Acquisition: A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated.

Evidence Synthesis: Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery.

Conclusions: ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.
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http://dx.doi.org/10.1016/j.clnu.2013.09.014DOI Listing
December 2013

Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?

Eur Urol 2014 Feb 22;65(2):263-6. Epub 2013 Oct 22.

Academic Urology Unit, University of Sheffield, Sheffield, UK.

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.
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http://dx.doi.org/10.1016/j.eururo.2013.10.011DOI Listing
February 2014

Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways.

Reg Anesth Pain Med 2011 Jan-Feb;36(1):63-72

McGill University Health Center, Department of Anesthesia, Montreal General Hospital, Quebec, Canada.

Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs.In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements of fast-track methodologies, were identified. The impact of epidural and paravertebral blockade, spinal analgesia, peripheral nerve blocks, and new regional anesthesia techniques on main procedure-specific postoperative outcomes is discussed. Finally, in the last section, implementations required to improve the role of regional anesthesia in the context of fast-track programs are suggested, and issues not yet addressed are presented.
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http://dx.doi.org/10.1097/AAP.0b013e31820307f7DOI Listing
July 2012

Intravenous lidocaine versus thoracic epidural analgesia: a randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program.

Reg Anesth Pain Med 2011 May-Jun;36(3):241-8

Departments of Anesthesia and Surgery, McGill University Health Centre, Montreal, Quebec, Canada.

Background And Objective: Laparoscopy, thoracic epidural analgesia, and enhanced recovery program (ERP) have been shown to be the major elements to facilitate the postoperative recovery strategy in open colorectal surgery. This study compared the effect of intraoperative and postoperative intravenous (IV) lidocaine infusion with thoracic epidural analgesia on postoperative restoration of bowel function in patients undergoing laparoscopic colorectal resection using an ERP.

Methods: Sixty patients scheduled for elective laparoscopic colorectal surgery were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or IV lidocaine infusion (IL group) (1 mg/kg per hour) with patient-controlled analgesia morphine for the first 48 hours after surgery. All patients received a similar ERP. The primary outcome was time to return of bowel function. Postoperative pain intensity, time out of bed, dietary intake, duration of hospital stay, and postoperative complications were also recorded.

Results: Mean times and SD (95% confidence interval) to first flatus (TEA, 24 [SD, 11] [19-29] hrs vs IL, 27 [SD, 12] [22-32] hrs) and to bowel movements (TEA, 44 ±19 [35-52] hrs vs IL, 43 [SD, 20] [34-51] hrs) were similar in both groups (P = 0.887). Thoracic epidural analgesia provided better analgesia in patients undergoing rectal surgery. Time out of bed and dietary intake were similar. Patients in the TEA and IL groups were discharged on median day 3 (interquartile range, 3-4 days), P = 0.744. Sixty percent of patients in both groups left the hospital on day 3.

Conclusions: Intraoperative and postoperative IV infusion of lidocaine in patients undergoing laparoscopic colorectal resection using an ERP had a similar impact on bowel function compared with thoracic epidural analgesia.
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http://dx.doi.org/10.1097/AAP.0b013e31820d4362DOI Listing
March 2012
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