Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

JE. Baack Kukreja, M Kiernan, B Schempp, A Siebert, A Hontar, B Nelson, J Dolan, K Noyes, A Dozier, A Ghazi, HH. Rashid, G Wu, EM. Messing. Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study. British Journal of Urology International Volume 119, Issue 1. January 2017 Pages 38-49

What is already known:

Radical cystectomy is on paper one of the surgeries most suited to benefit from a comprehensive ERAS programme – elderly population, long lengths of hospital stay and high morbidity rates. Despite this uptake of ERAS programmes have been slow.

What this paper adds:

This US study analysed sequential patents before and after the introduction of an ERAS protocol in their institution using a propensity matched approach. They used a comprehensive ERAS programme including pre-operative counselling focusing on stoma care and discharge planning, carbohydrate loading and probiotics; intraoperative fluid management and “avoidance of salt and fluid overload” – using either pulse pressure variation or oesophageal Doppler, opiate avoiding analgesia – epidural for open procedure and local anaesthesia for laparoscopic surgery, they also included the use of oral alvimopan (a peripheral acting -opioid antagonist); with early mobilisation and early oral nutrition postoperatively. They demonstrated a significant reduction in hospital length of stay (5 vs 8 days, p<0.001), with no change in complications (although ileus rates were decreased) but also importantly showed no change readmission rates. Interestingly given the goal to avoid salt and fluid overload there was no difference in the amount of fluid given (both groups received on average 6 litres of fluid intraoperatively), but despite this the ileus rate still improved.

Chris Jones, Guildford.