A good first step for ERAS in otolaryngoiatric field, but not enough

Dear editor

We read thoroughly the article by Liao et al¹ “Decreased hospital charges and postoperative pain in septoplasty by application of enhanced recovery after surgery” and we found it very interesting and innovative, given the low level of evidence about the application of the enhanced recovery after surgery (ERAS) protocol in otolaryngologic field. Nevertheless, there are some points that we have focused on since they remain unclear and decrease the scientific reliability of the results. First, we have noticed that the primary endpoint is not well defined, and this is reflected in the whole setting of the study: randomization method, allocation of the patients, statistical analysis, and results. Whilst perioperative management of the ERAS group is quite well described, however, the “common processing” of the control group remains undefined. In our opinion, for all these reasons, readers cannot fully understand the author’s objective, thus making this study difficult to reproduce.

Moreover patients in the ERAS group were managed with local anesthesia and postoperative administration of oral nonsteroidal anti-inflammatories (NSAIDs), differently from the control group, which only received general anesthesia and no postoperative analgesia. This affects evaluation of real benefits of the innovative surgical approach, consisting of the avoidance of postoperative nasal filling and the use of a new nasal septum suture.

According to the study results, in the ERAS group there was a decrease in the hospital stay of 1.4 days (4.4 vs 5.8) compared with that in the control group. This positive result could be improved if we consider that other authors shortened more endoscopic septoplasty length of stay, having fewer long-stay patients (>48 hours).² In the present literature there are no adequate neither standardized studies about septoplasty costs analysis; indeed the author’s aim to evaluate hospital charges is desirable. From this perspective, the choice of sedation anesthesia instead of general anesthesia in the ERAS group could be a suitable manner to reduce healthcare costs, total operation time, and postoperative complications.³

Disclosure

The authors report no conflicts of interest in this communication.

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References

1.		Liao Z, Liao W, Tan KS, et al. Decreased hospital charges and postoperative pain in septoplasty by application of enhanced recovery after surgery. Ther Clin Risk Manag. 2018;14:1871–1877.
2.		Champagne C. Endoscopic vs conventional septoplasty: a review of the literature. Eur Ann Otorhinolaryngol Head Neck Dis. 2016;133(1):43–46
3.		Hayrettin D. Septoplasty: under general or sedation anesthesia. Which is more efficacious? Eur Arch Otorhinolaryngol. 2014;271(9):2433–2436.

Authors’ reply

Zhenpeng Liao,^1,* Wei Liao,^1,* Kai Sen Tan,^2,* Yueqi Sun,³ Aiqing Peng,¹ Yingxian Zhu,⁴ Haixin He,¹ Shuowei Yang,¹ Guangfu Xu,¹ Rongfei Su,¹ Jinyu Yao,³ Yunping Fan,¹ Qintai Yang,⁵ Haiyu Hong¹

¹Department of Otolaryngology, Allergy Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People’s Republic of China; ²Department of Otolaryngology, National University of Singapore, National University Health System, Singapore, Singapore; ³Department of Otolaryngology, Otorhinolaryngology Hospital, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China; ⁴Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People’s Republic of China; ⁵Department of Otolaryngology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China

Correspondence: Qintai Yang, Department of Otolaryngology, The Third Affiliated Hospital of Sun Yat-sen University, No 600, Tianhe Road, Guangzhou 510630, People’s Republic of China, Tel +86 137 2485 9848, Email [email protected]

Haiyu Hong, Department of Otolaryngology, Allergy Center, The Fifth Affiliated Hospital of Sun Yat-sen University, No 52, Meihua East Road, Zhuhai 519020, People’s Republic of China, Tel +86 138 2307 0089, Email [email protected]

Dear editor

Thank you for your comments and suggestions on this article.

Regarding the first point, the primary endpoint of this study was the length of hospital stay and postoperative pain. In addition, secondary endpoints such as nasal congestion, sleep disorder, anxiety and other conditions were also observed to improve in the study. With regards to “common processing” of the control group, it refers to the standard procedure of each region which varies and therefore it was difficult to describe in detail. A common denominator of the “common processing” is that the current hospital standard in the region for treating septoplasty was performed, without considering ERAS implementation. Therefore, the design suits the objective of the study in comparing treatment procedure with and without ERAS implementation.

In this study, the main evaluation is the application of ERAS as a means of avoiding the postoperative nasal filling that were found as a major contributor to post-operative discomfort. Therefore, the study did not account for comparison of the individual procedure. However, the point raised is an interesting one and we may look into individually evaluating the surgical procedure alone in the future with more comparable anesthetic procedure.

Thank you for the suggestion in further improving the hospitalization time. The modest decrease of hospitalization time in ERAS group by 1.4 days (4.4 vs 5.8) (<48 h) shows that our ERAS implementation is still in the preliminary stage and can still be further improved. The suggestions will surely contribute to the further refinement of the ERAS procedure in the otolaryngologic field.

Overall, we concur with the letter that the implementation of ERAS requires further refinement. The purpose of our study is to show the feasibility of ERAS implementation in the Otolaryngologic field and its potential benefits towards hospital charges and patient quality of life. We hope that we have sufficiently addressed the points in the letter and we welcome any future correspondence.

Disclosure

The authors report no conflicts of interest in this communication.

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