Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

[Colorectal endometriosis surgery: Technical and technological innovations in service of a complex surgery]

INTRODUCTION

Digestive endometriosis represents the most common form of deep endometriosis, significantly impacting patients' quality of life. The optimization of its surgical management has been marked by major technological advances. This review explores the evolution of colorectal endometriosis surgery, highlighting the progress in laparoscopy, the contribution of robotics, the shift towards organ preservation, and the optimization of postoperative care.

METHODS

A systematic literature search was conducted in the PubMed and Embase databases, focusing on clinical studies, meta-analyses, and international guidelines published between 1980 and 2025. Articles were selected based on their relevance to technical advancements and clinical outcomes.

RESULTS

Laparoscopy has replaced laparotomy, leading to a reduction in complications and an improvement in postoperative quality of life. Robotics, while not a groundbreaking revolution, provides advantages in precision and surgeon comfort. Conservative procedures have emerged as safe alternatives to systematic extensive segmental resection. Indication criteria have evolved to favor strategies tailored to the depth and extent of lesions while minimizing complication risks and preserving digestive function and quality of life. The standardization of procedures, the abandonment of systematic protective ileostomy, and enhanced recovery protocols have contributed to reducing surgical morbidity and improving patients' quality of life.

CONCLUSION

Technical and technological advancements have transformed colorectal endometriosis surgery. Surgical strategies are shifting towards personalized approaches, integrating minimally invasive surgery and optimized multidisciplinary management. The future lies in the continuous improvement of techniques and the better standardization of surgical indications.

Usefulness of intraoperative colonoscopy and synchronous scoring system for determining the integrity of the anastomosis in left-sided colectomy: a single-center retrospective cohort study

OBJECTIVES

The aim of this study is to evaluate the utilization of intraoperative colonoscopy (IOC) for determining the integrity of the anastomosis and to establish an IOC scoring system.

METHODS

A retrospective cohort study was conducted from January 2021 to June 2024, we analyzed the clinical data of 160 patients registered in a database who underwent laparoscopic left-sided colectomy at Pusan National University Yangsan Hospital. IOC was performed on all patients, and Mucosal color (MC), stapled line bleeding (BL), proximal redundancy (PR), and bowel preparation (BP) were evaluated and scored as variables. Logistic regression analysis was used to evaluate risk factors for anastomotic leakage (AL) and Cohen's kappa was applied to assess the reproducibility of the evaluation.

RESULTS

Of 160 patients, 10 (6.25%) experienced AL. All the IOC variables had kappa values of 0.8 or higher, indicating good agreement. The logistic regression analysis revealed significant differences in the MC 2 (P = 0.017, OR 12.86), PR 2 (P = 0.001, OR 27.64), BP 2 (p = 0.016, OR 10.50) PR 2 score (P = 0.016, OR 10.50) and the sum of the scores (p = 0.001, OR 3.51).

CONCLUSION

IOC can be performed as a reference procedure to assess the integrity of the anastomosis during left-sided colorectal surgery.

Pediatric enhanced recovery after surgery (ERAS): Advancements and outcomes in the last 5 years

PURPOSE OF REVIEW

The aim is to describe recent advances in pediatric enhanced recovery after surgery (ERAS) in all phases of care as well as the outcomes and impact of recent evidenced-based pathways in pediatric patients.

RECENT FINDINGS

While profoundly impactful in the care of adult patients for nearly 3 decades, ERAS had a slower start in pediatric care that began approximately 10 years ago. Early outcomes were promising, and the multidisciplinary approach to perioperative care has gained momentum, with recent single-center studies of ERAS for pediatric patients showing reductions in both complications and length of stay. The first ERAS Society recommendations for pediatric patients were published in 2024, and two multicenter trials of pediatric ERAS, Pediatric urology recovery after surgery endeavor and ENhanced Recvovery in CHildren Undergoing Surgery (ENRICH-US), have completed enrollment and are expected to publish results in 2025.

SUMMARY

ERAS in pediatric practice has made great strides in the past 5 years and has led to improved outcomes for young patients. Multicenter trial outcomes and the development of additional rigorous ERAS Society recommendations for children will guide future care.

Malnutrition and perioperative nutritional rehabilitation in major operations

Background

Malnutrition is a potentially preventable risk factor for surgery. This systematic review examines nutritional management strategies aiming to enhance surgical outcomes.

Methods

A systematic search was conducted in PubMed for English-language studies published between July 1, 2004, and July 1, 2024, involving adult surgical patients. Study selection focused on four key themes: (1) nutritional screening and assessment, (2) preoperative nutritional therapy, (3) nutritional support in critically ill surgical patients, and (4) postoperative nutritional rehabilitation. Studies in non-surgical cohorts, letters, and case reports were excluded. Reference lists of relevant studies were manually screened for additional sources.

Results

Of 2763 studies identified, 251 met the inclusion criteria and 85 were added after manual screening, contributing to a total of 341 papers for the review. The prevalence of malnutrition varied widely by procedure, with the highest rates observed in pancreatic and esophagogastric operations. Preoperative malnutrition was strongly associated with increased postoperative complications, infections, prolonged hospital stay, and higher mortality. The Malnutrition Universal Screening Tool (MUST) was effective in identifying at-risk patients. Preoperative nutritional interventions, including dietitian-led counseling, oral supplementation, and enteral or parenteral nutrition, may reduce complications and improve outcomes. Critically ill patients benefited from structured enteral and parenteral strategies. Early postoperative nutrition within enhanced recovery after surgery (ERAS) protocols are linked to less complications and shorter hospital stay.

Conclusion

Malnutrition significantly impacts surgical outcomes, necessitating early identification and intervention. Standardized management is key to improving recovery and reducing complications. Future research should focus on refining diagnostic tools, assessing nutritional requirements, optimizing perioperative nutritional strategies, and establishing long-term nutritional follow-up guidelines for surgical patients.

A Prospective Mixed Methods Study on Experiences of Mindfulness Intervention on Pain and Anxiety in Patients Undergoing a Colorectal Surgery

Purpose: To evaluate the effectiveness and experiences of a mindfulness intervention in colorectal surgical patients. Design of Study: Descriptive mixed methods study. Method: Sixteen participants were provided with two or three 15-20-min mindfulness sessions. Data were collected before and after each session on blood pressure, heart and respiratory rate, anxiety, and pain. The participants were interviewed before their discharge. Findings: Eight participants (n = 8) received two and eight (n = 8) three sessions. Decreasing blood pressure and lower heart rates were noted after the sessions. Also, decreasing pain scores were found, especially in participants who attended two sessions. Minor decrease in anxiety scores were noticed in participants who attended three sessions. Two major themes emerged from the interviews: healing and restoration of health and becoming in tune with self. These themes were characterized by study participants' reflections on experience of recovery, progression to physical relaxation, pathway to serenity, awareness of emotions, evolution of perceptions and experiences of mindfulness. Conclusions: The physiological changes to mindfulness intervention, composed of two or three sessions, were minor and challenging to measure to demonstrate effects. However, study participants' experiences were very positive and suggest that this intervention could prove to be beneficial for colorectal surgical patients.

Factors predicting lower hospital stay after liver transplantation using a comprehensive enhanced recovery after surgery (ERAS) protocol

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols facilitate patient recovery without increasing complication rates. An ERAS protocol designed for our liver transplant (LT) patients obtained a median hospital length of stay (LOS) of 4 days. However, a proportion of patients do not achieve early discharge. This study aimed to identify factors that predict an LOS≤ 4 days.

METHODS

Identifying factors associated with LOS <4 days in our LT patients.

RESULTS

We performed 293 LTs (2012-2021), LOS≤4 days in 171 (58.4 %). The following factors emerged as statistically predictors of LOS≤4 days in the univariate analysis: male sex, HCC or HCV patients, lower MELD score, lower BAR score, no DCD patients, shorter operative time, no intraoperative transfusion, shorter ICU stay, no Clavien-Dindo complications grade ≥ III, no primary graft dysfunction, no acute rejection, no readmission at 30 days and no retransplantation were associated to LOS≤4 days. However, in the multivariate analysis, the only independent risk factor that predicted LOS≤4 days was the presence of hepatocarcinoma. DCD donors and higher MELD score were negative factors.

CONCLUSIONS

Applying ERAS programs in LT patients is beneficial, safe and extensible to all patients, but those with hepatocarcinoma obtain higher rates of LOS≤4 days.

Pain, opioid consumption, and epidural anesthesia in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy: an observational cohort study

BACKGROUND

Surgery is often needed to provide disease control in patients with inflammatory bowel disease. Studies document increased postoperative pain and complicated perioperative courses. This study examines postoperative pain and opioid consumption in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy. Furthermore, the impact of epidural anesthesia is investigated.

METHODS

This study encompassed an observational cohort of patients with inflammatory bowel disease undergoing subtotal colectomy in the period 1 January 2018 to 30 June 2023 at a university hospital in Denmark. Demographic and perioperative data, opioid consumption, pain scores, and procedural data of epidural anesthesia were retrieved from patient records. Data were stratified according to the use of epidural anesthesia.

RESULTS

The study included 153 patients. Overall, 45% of patients received epidural anesthesia. Opioid consumption in the postoperative care unit was 9.2 mg (3.3-15.8 mg) and 3.8 mg (0-15 mg) (P = 0.04) in patients without and with epidural anesthesia, respectively. Correspondingly, opioid consumption during the first 24 h postoperatively was 23.3 mg (10-33 mg) and 6.8 mg (0-21.7 mg) (P < 0.001). Numerical rating scale (NRS) pain in the postoperative care unit was 3.5 (2-4.6) and 2.7 (1.3-4.3) in patients without and with epidural anesthesia, respectively (P = 0.1645). Thirty percent of patients treated with epidural anesthesia experienced ≥ 1 adverse event(s) related to epidural anesthesia.

CONCLUSIONS

Our study demonstrates a relatively low consumption of opioids and low pain scores in the early postoperative period following laparoscopic subtotal colectomy regardless of the use of epidural anesthesia. Epidural anesthesia was associated with a substantial frequency of adverse events.

Impact of Preoperative CT-Measured Sarcopenia on Clinical, Pathological, and Oncological Outcomes After Elective Rectal Cancer Surgery

Background: Patients with rectal cancer may be exposed to a loss of muscle strength and quality. This study aimed to assess the role of preoperative CT-based sarcopenia on postoperative clinical, pathological, and oncological outcomes after rectal cancer surgery. Methods: This retrospective monocentric study included patients who underwent elective oncologic resection for rectal adenocarcinoma between 01/2014 and 03/2022. The skeletal muscle index (SMI) was measured using CT at the third lumbar vertebral level, and sarcopenia was defined based on pre-established sex-specific cut-offs. Patients with sarcopenia were compared to those without sarcopenia in terms of outcomes. A Cox proportional hazard regression analysis was used to determine the independent prognostic factors of disease-free survival (DFS) and overall survival (OS). Results: A total of 208 patients were included, and 123 (59%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (66 vs. 61 years, p = 0.003), had lower BMI (24 vs. 28 kg/m2, p < 0.001), and were mainly men (76 vs. 48%, p < 0.001). There was no difference in overall and major complication rates between the sarcopenia and non-sarcopenia group (43 vs. 37%, p = 0.389, and 17 vs. 17%, p = 1.000, respectively). Preoperative and postoperative features related to rectal surgery were comparable. The only predictive factor impacting OS was R1/R2 resection (HR 4.915, 95% CI, 1.141-11.282, p < 0.001), while sarcopenia (HR 2.013, 95% CI 0.972-4.173, p = 0.050) and T3/T4 status (HR 2.108, 95% CI 1.058-4.203, p = 0.034) were independently associated with DFS. Conclusions: A majority of patients undergoing rectal cancer surgery had preoperative CT-based sarcopenia. In this cohort, sarcopenia had no impact on postoperative morbidity and OS but was independently associated with DFS.

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

An Online Preoperative Screening Tool to Optimize Care for Patients Undergoing Cancer Surgery: A Mixed-Method Study Protocol

BACKGROUND/OBJECTIVE

Despite surgery being the primary curative treatment for cancer, patients with compromised preoperative physical, nutritional, and psychological status are often at a higher risk for complications. While various screening tools exist to assess physical, nutritional, and psychological status, there is currently no standardised self-reporting tool, or established cut-off points for comprehensive risk assessment. This study aims to develop, validate, and implement an online self-reporting preoperative screening tool that identifies modifiable risk factors in cancer surgery patients.

METHODS

This mixed-methods study consists of three distinct stages: (1) Development-(i) a scoping review to identify available physical, nutritional, and psychological screening tools; (ii) a Delphi study to gain consensus on the use of available screening tools; and (iii) a development of the online screening tool to determine patients at high risk of postoperative complications. (2) Testing-a prospective cohort study determining the correlation between at-risk patients and postoperative complications. (3) Implementation-the formulation of an implementation policy document considering feasibility.

CONCLUSIONS

The timely identification of high-risk patients, based on their preoperative physical, nutritional, and psychological statuses, would enable referral to targeted interventions. The implementation of a preoperative online screening tool would streamline this identification process while minimising unwarranted variation in preoperative treatment optimisation. This systematic approach would not only support high-risk patients but also allow for more efficient provision of surgery to low-risk patients through effective risk stratification.

Breaking surgical barriers: ERAS in action in Romania

Implementing Enhanced Recovery After Surgery (ERAS) protocols presents challenges for healthcare systems, particularly for patients undergoing complex surgeries. Though ERAS effectively reduces postoperative complications and hospital stays, its implementation varies. Our hospital adopted the ERAS protocol in 2020. This study details specific ERAS components implemented in our clinic, emphasizing surgical and anesthetic strategies. We describe preoperative, intraoperative, and postoperative phases and analyze the evidence for each component's integration. Additionally, we highlight the specific challenges faced in Romania, such as funding limitations, resource constraints, and reluctance among healthcare professionals. We conducted a prospective study of 147 patients with colorectal cancer treated from 2020 to 2023, detailing the perioperative care phases and supporting evidence for protocol components. The methodology was refined to account for potential confounding factors by ensuring consistency in patient selection criteria and perioperative management. Despite ERAS's advantages, patients and staff resisted its implementation. In Romanian hospitals, colorectal surgery uses ERAS only in limited cases due to inadequate funding, insufficient medical personnel, logistical challenges, and a lack of awareness or skepticism among healthcare professionals and patients. The study presents specific clinical outcomes, including length of hospital stay (LOS), postoperative complications, and readmission rates among ERAS patients. We recommend expanding medical networks and utilizing advanced technologies like telemedicine services and home-based care to improve ERAS protocol adherence. Furthermore, educational programs are essential to increase awareness and compliance with ERAS principles among patients and healthcare providers.

The Impact of Enhanced Recovery After Surgery Compliance in Colorectal Surgery for Cancer

Background: This study aimed to assess the impact of Enhanced Recovery After Surgery (ERAS) compliance and to identify which components of this protocol are most likely to affect postoperative outcomes in patients undergoing colorectal cancer surgery. Methods: This is a retrospective cohort evaluating patients who underwent elective colon resection. ERAS compliance was assessed based on adherence to the protocol components. The study examined the following outcomes: postoperative complications, readmission rates, mortality, conversion to open surgery, stoma creation, and length of hospital stay. Results: Of the 410 patients studied, 59% achieved ≥75% compliance. Comparison between compliance groups (<75% versus ≥75%) showed significant differences in overall complications (P = .002), severe complications (P = .001), and length of hospital stay (P < .001). The area under the receiver operating characteristic curve for predicting the absence of severe complications based on ERAS compliance was 0.677 (95% confidence interval: 0.602-0.752). Logistic regression analyses demonstrated that ERAS compliance was significantly associated with a reduced risk of severe complications (P < .001), as well as that the following items: avoiding prophylactic drains (P < .001), minimal use of postoperative opioids (P = .045), avoidance of postoperative salt and water overload (P < .001), postoperative nutritional support (P = .048), and early mobilization (P = .025). Conclusion: High ERAS compliance is associated with improved postoperative outcomes in colorectal cancer surgery. Key protocol components for preventing severe complications include avoiding prophylactic drains, minimal postoperative opioid use, avoiding salt and water overload, nutritional support, and early mobilization.

Feasibility of an < 24 h discharge pathway with tele-monitoring after elective colectomies: a pilot study

INTRODUCTION

Implementation of enhanced recovery after surgery principles has led to exploration of ambulatory pathways in surgery, including gastrointestinal surgery. However, implementation of ambulatory pathways after colorectal surgery has not been established yet. Previous studies suggest that discharge within 24 h in colorectal surgery is only possible with a clear protocol and careful patient selection.

METHODS

Single center prospective feasibility pilot study of thirty patients in one large non-academic teaching hospital in the Netherlands. Patients were included if they were between 18 and 80 years old, underwent elective minimal invasive colonic resection with anastomosis, had a ASA-score of I or II, fully understood the procedure, had a person at home the first 4 days after surgery and lived within 30 min travel radius to the hospital. Exclusion criteria were cT4 tumours, multi-visceral resections, insulin-dependent diabetes, anti-coagulants which required perioperative bridging, and perioperative complications. Patients followed a pathway with discharge within 24 h postoperatively and were monitored by a tele-monitoring smartphone application after discharge.

RESULTS

Thirty patients were included and twenty-one patients (70%) fulfilled discharge criteria within 24 h after surgery. Six (20%) patients were readmitted within 30 days. Complications occurred in six (20%) patients, which was classified as Clavien-Dindo ≥ 3 complication in one (3%) patient. Patients and health care provider satisfaction was high.

CONCLUSION

Findings of this study support the feasibility and safety of an early discharge protocol with tele-monitoring after minimal invasive colonic resection. Satisfaction of patients and health care providers was high.

[Prognostic value of body composition in oncological visceral surgery]

Screening of nutritional status of cancer patients plays a crucial role in the perioperative management and is mandatory for the certification of oncological centers by the German Cancer Society (DKG). The available screening tools do not differentiate between muscle and adipose tissue. Recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) as well as the automatic picture archiving communication system (PACS) imaging analysis by high performance reconstruction systems have recently enabled a detailed analysis of adipose tissue and muscle quality. Rapidly growing evidence shows that body composition parameters, especially reduced muscle mass, are associated with adverse outcomes in cancer patients and have been reported to negatively affect overall survival (OS), disease-free survival (DFS), toxicity associated with chemotherapy and surgical complications. In this article, we summarize the recent literature and present the clinical influence of body composition in oncological visceral diseases.

Simplified Enhanced Recovery After Surgery Intraoperative Fluid Management

INTRODUCTION

This study evaluates the efficacy of a simplified intraoperative fluid administration metric within enhanced recovery after surgery (ERAS) pathways. The objective is to optimize fluid management to improve postoperative outcomes, specifically kidney function.

METHODS

A retrospective evaluation was conducted at Massachusetts General Hospital on adult patients who underwent open hysterectomy, colectomy, and gastrectomy as part of ERAS pathways. The proposed fluid metric, set at 500 mL/h, was assessed against traditional methods of fluid administration. Data on serum creatinine (Cr) changes as defined as the difference between the baseline value and the maximum value within 1 week of surgery were collected, and compliance with the metric was monitored. Analysis involved Wilcoxon rank-sum test, Kruskal-Wallis test, and quantile regression.

RESULTS

The study included 1028 patients. Regression analysis indicated that compared to patients who received the optimal fluid quantity, those receiving below the optimal range showed an absolute increase in median Cr levels of 0.03 mg/dl (95% confidence interval = -0.005, 0.05) while those who received above the optimal range demonstrated an absolute increase in median Cr level of 0.01 (95% confidence interval = -0.03, 0.05).

CONCLUSIONS

The new fluid metric demonstrated a balanced approach to fluid administration, reducing the risk of overhydration while maintaining sufficient hydration. Additionally, implementing a simplified fluid metric of 500 mL/h in ERAS pathways is effective in improving postoperative kidney function. This approach facilitates adherence to fluid guidelines and can be applied across various healthcare settings. This metric serves as a practical, evidence-based pathway for fluid administration for most patients undergoing most ERAS procedures.

Implementation of a Multidisciplinary Enhanced Recovery After Surgery (ERAS) Program for Cytoreductive Surgery (CRS) With Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

BACKGROUND AND OBJECTIVES

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can be associated with prolonged hospital stays. A novel Enhanced Recovery After Surgery (ERAS) based on ERAS Society guidelines was designed and implemented. The primary outcome was ERAS compliance. Secondary outcomes included length of stay (LOS) and postoperative complications.

METHODS

A retrospective study on patients who underwent CRS/HIPEC between 2018 and 2022, with ERAS implementation in 2022. Health records were reviewed. Statistical analysis included descriptive statistics, Wilcoxon tests, Student t-test, and χ2 and binomial negative regression. Health Ethics Research Board approval was obtained.

RESULTS

Eighty patients underwent CRS/HIPEC: 59 in the pre-ERAS group and 21 in the post-ERAS group. Groups were similar in age, comorbidities, and Peritoneal Carcinomatosis Index. ERAS compliance increased from 32.8% to 70.8% (p < 0.001). Median LOS decreased from 14 to 9 days (p < 0.001). Comparing pre-ERAS to post-ERAS showed no significant difference in the major morbidity rate (13.6% vs. 9.5%) or 30-day readmission (9.4% vs. 4.8%) and no mortalities. Controlling for patient characteristics, the mean LOS decreased by 6.94 days (p < 0.001).

CONCLUSION

Implementation of an ERAS CRS/HIPEC program is safe and allows for improved compliance to ERAS protocols and a significant reduction in LOS.

Enhanced Recovery after Surgery - Evidence and Practice

AbstractEnhanced Recovery After Surgery (ERAS) is a global initiative comprised of a series of evidence-based interventions in the preoperative, intraoperative, and postoperative surgical phases. When implemented as a bundle, ERAS interventions both improve clinical outcomes and provide cost savings to the health care system. This review provides an update on the current evidence for individual ERAS elements to improve quality of care as well as practical recommendations for multidisciplinary teams to implement their own ERAS programs.

Enhanced rehabilitation after surgery: principles in the treatment of emergency complicated colorectal cancers - a narrative review

Enhanced Recovery After Surgery (ERAS) protocols are used in elective colorectal surgeries and have shown improved recovery for many patients. However, using these protocols in emergency colorectal surgery, especially in complicated cases of obstructive colorectal cancer, is still debated. This review examined the ERAS principles that can be adapted for emergencies. We reviewed the literature on applying ERAS principles in emergency colorectal cancer surgery. We analyzed key strategies used before, during, and after surgery. The aim of ERAS in emergency colorectal surgery is to reduce physical stress from urgent surgical conditions. Before surgery, the focus should be on early patient recovery, managing blood sugar levels, and providing patient education when possible. Minimally invasive techniques, careful fluid management, and effective pain relief during surgery are intraoperative key points. After surgery, early feeding, patient mobilization, and minimizing the use of medical devices are encouraged. Studies have shown that using ERAS in emergencies can lower mortality, reduce hospital stays, and influence patient recovery rates, although it may lead to higher initial costs. Still, following ERAS in emergencies is inconsistent due to logistical issues and patient health changes. More people are starting to recognize the benefits of ERAS in obstructive colorectal cancer surgery. Although there is less evidence compared to elective procedures, new studies suggest that organized steps for care can improve patient outcomes. Further research is needed to improve ERAS emergency protocols and identify patients suitable for this approach so that healthcare resources can be used better.

Effectiveness of tramadol or topic lidocaine compared to epidural or opioid analgesia on postoperative analgesia in laparoscopic colorectal tumor resection

BACKGROUND

Chronic postoperative pain is the most common postoperative complication that impairs quality of life. Postoperative pain gradually develops into neuropathic pain. Multimodal analgesia targets multiple points in the pain pathway and influences the mechanisms of pain chronification.

PATIENTS AND METHODS

We investigated whether a lidocaine patch at the wound site or an infusion of metamizole and tramadol can reduce opioid consumption during laparoscopic colorectal surgery and whether the results are comparable to those of epidural analgesia. Patients were randomly divided into four groups according to the type of postoperative analgesia. Group 1 consisted of 20 patients who received an infusion of piritramide. Group 2 consisted of 21 patients who received an infusion of metamizole and tramadol. Group 3 consisted of 20 patients who received patient-controlled epidural analgesia. Group 4 consisted of 22 patients who received piritramide together with a 5% lidocaine patch on the wound site. The occurrence of neuropathic pain was also investigated.

RESULTS

Piritramide consumption was significantly lowest in group 3 on the day of surgery and on the first and second day after surgery. Group 4 required significantly less piritramide than group 1 on the day of surgery and on the first and second day after surgery. The group with metamizole and tramadol required significantly less piritramide than groups 1 and 4 on the first and second day after surgery. On the day of surgery, this group required the highest amount of piritramide.

CONCLUSIONS

Weak opioids such as tramadol in combination with non-opioids such as metamizole were as effective as epidural analgesia in terms of postoperative analgesia and opioid consumption. A lidocaine patch in combination with an infusion of piritramide have been able to reduce opioid consumption.

Feasibility of a Comprehensive eCoach to Support Patients Undergoing Colorectal Surgery: Longitudinal Observational Study

BACKGROUND

The mainstay of colorectal cancer care is surgical resection, which carries a significant risk of complications. Efforts to improve outcomes have recently focused on intensive multimodal prehabilitation programs to better prepare patients for surgery, which make the perioperative process even more complex and demanding for patients. Digital applications (eCoaches) seem promising tools to guide patients during their care journey. We developed a comprehensive eCoach to support, guide, and monitor patients undergoing elective colorectal surgery through the perioperative phase of the care pathway.

OBJECTIVE

The primary aim of this study was to determine its feasibility, in terms of recruitment rate, retention rate, and compliance. Also, usability and patient experience were examined.

METHODS

A single-center cohort study was conducted from April to September 2023 in a tertiary teaching hospital in the Netherlands. All elective colorectal surgery patients were offered an eCoach that provided preoperative coaching of the prehabilitation protocol, guidance by giving timely information, and remote monitoring of postoperative recovery and complications. Recruitment and retention rate, as well as compliance for each part of the care pathway, were determined. Secondary, patient-reported usability measured by the Usefulness, Satisfaction, and Ease of Use questionnaire and patient experiences were reported.

RESULTS

The recruitment rate for the eCoach was 74% (49/66). Main reasons for exclusion were digital illiteracy (n=10), not owning a smartphone (n=3), and the expected burden of use being too high (n=2). The retention rate was 80% (37/46). Median preoperative compliance with required actions in the app was 92% (IQR 87-95), and postoperative compliance was 100% (IQR 100-100). Patient-reported usability was good and patient experiences were mostly positive, although several suggestions for improvement were reported.

CONCLUSIONS

Our results demonstrate the feasibility of a comprehensive eCoach for guiding and monitoring patients undergoing colorectal surgery encompassing the entire perioperative pathway, including prehabilitation and postdischarge monitoring. Compliance was excellent for all phases of the care pathway and recruitment and retention rates were comparable with rates reported in the literature. The study findings provide valuable insights for the further development of the eCoach and highlight the potential of digital health applications in perioperative support.

Nutritional Assessment and Management of Patients with Brain Neoplasms Undergoing Neurosurgery: A Systematic Review

BACKGROUND/AIM

Nutritional management in neurosurgical patients with brain neoplasms is critical, as optimal nutritional status is potentially associated with improved clinical outcomes. This systematic review aimed to analyze the impact of pre- and postoperative nutritional assessment and effect of prepost interventions on the clinical outcomes.

METHODS

A systematic review was conducted using the PubMed, Cochrane Library, Embase, and CINAHL databases, complemented by a search of grey literature. Study quality was assessed using the Joanna Briggs Institute framework, and the certainty of evidence was graded according to the Oxford Centre for Evidence-Based Medicine levels.

RESULTS

Fourteen studies, encompassing a total of 11,224 adult patients with brain neoplasms, were included. Many of these studies were retrospective, had small sample sizes, and examined diverse nutritional protocols. Preoperative nutritional status assessment, including clinical parameters such as albumin (p < 0.001), Controlling Nutritional Status score (p = 0.001), and Prognostic Nutritional Index (p < 0.010), combined with postoperative oral nutritional supplements (p < 0.001), was significantly associated with postoperative clinical outcomes. Additionally, personalized nutritional counseling contributed to a reduction in complications and facilitated more effective functional recovery.

CONCLUSIONS

Nutritional care is vital in managing neurosurgical patients with brain neoplasms, reducing complications and enhancing postoperative recovery and overall clinical outcomes. A multidisciplinary team is key to optimal outcomes. Future research should aim to standardize protocols for broader applicability.

The Effect of Neuromuscular Electrical Stimulation on Muscle Proteolysis, Muscle Mass and Strength, Cardiorespiratory Fitness, Functional Activity, and Quality of Life in Post-Cardiac Surgery Patients: A Narrative Review

Advances in medical and surgical practices, along with enhanced cardiac ICU services, have led to a substantial increase in cardiac surgeries (CS). Consequently, CS is now more frequently performed on older patients undergoing complex procedures, which results in higher rates of postoperative complications (POC) such as muscle proteolysis, prolonged hospital stays and worsened clinical and functional outcomes. These complications can delay early mobilization (EM) programs and exercise as core components of post-CS rehabilitation even though sometimes they fail to prevent functional decline. Neuromuscular electrical stimulation (NMES) has emerged as a physical modality to prevent muscle atrophy, improve muscle strength (MS), and enhance overall functional ability in post-CS patients with physical limitations. Therefore, NMES has been chosen for post-operative patients with physical limitations. This review aimed to describe the effects of NMES on muscle proteolysis, muscle mass (MM) and strength (MS), cardiorespiratory fitness (CRF), functional activity, and quality of life (QoL) in post-CS patients. Data were synthesized from PubMed, Google Scholar, and CINAHL using relevant keywords, and the review included six original articles and one systematic review. Findings indicate that perioperative NMES does not significantly affect proteolysis; however, postoperative NMES appears to increase metabolism and reduce protein degradation, thereby preventing muscle weakness. Although NMES has been shown to enhance MS, its impact on increasing MM remains insignificant. Similarly, improvements in the 6-minute walk distance (6MWD), a measure of CRF, were not statistically significant, even if they were clinically meaningful. Secondary outcomes related to functional activity and QoL also did not show significant improvements. In conclusion, post-operative NMES stimulates protein anabolism and insignificantly improves MS and MM without significantly enhancing CRF as measured by 6MWD. This may explain the lack of significant improvements in functional activity and QoL in post-CS patients.

Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Major surgery for gastrointestinal cancer carries a 50% risk of postoperative complications. Physiotherapists commonly provide interventions to patients undergoing gastrointestinal surgery for cancer with the intent of preventing complications and improving recovery. However, the evidence is unclear if physiotherapy is effective compared to providing no physiotherapy, nor if timing of service delivery during the perioperative pathway influences outcomes. The objective of this review is to evaluate and synthesise the evidence examining the effects of perioperative physiotherapy interventions delivered with prophylactic intent on postoperative outcomes compared to no treatment or early mobilisation alone.

METHODS

A protocol was prospectively registered with PROSPERO and a systematic review performed of four databases. Randomised controlled trials examining prophylactic physiotherapy interventions in adults undergoing gastrointestinal surgery for cancer were eligible for inclusion.

RESULTS

Nine publications from eight randomised controlled trials were included with a total sample of 1418 participants. Due to inconsistent reporting of other perioperative complications, meta-analysis of the effect of physiotherapy was only possible specific to postoperative pulmonary complications (PPCs). This found an estimated 59% reduction in risk with exposure to physiotherapy interventions (RR 0.41, 95%CI 0.23 to 0.73, p < 0.001). Sub-group analysis demonstrated that timing of delivery may be important, with physiotherapy delivered only in the preoperative phase or combined with a postoperative service significantly reducing PPC risk (RR 0.32, 95%CI 0.17 to 0.60, p < 0.001) and hospital length of stay (MD-1.4 days, 95%CI -2.24 to -0.58, p = 0.01), whilst the effect of postoperative physiotherapy alone was less certain.

CONCLUSIONS

Preoperative-alone and perioperative physiotherapy is likely to minimise the risk of PPCs in patients undergoing gastrointestinal surgery for cancer. This challenges current traditional paradigms of providing physiotherapy only in the postoperative phase of surgery. A review with broader scope and component network analysis is required to confirm this.

Low rate of rescue epidural analgesia after open colorectal surgery with intrathecal morphine: a retrospective cohort study

PURPOSE

The use of intrathecal morphine in open colorectal surgery has been limited despite being a promising analgesic alternative used in other types of open abdominal surgery. Intrathecal morphine has a higher success rate than thoracic epidural analgesia, the current standard method of analgesia in open colorectal surgery. Intrathecal morphine is occasionally used in open colorectal surgery when thoracic epidural analgesia placement fails and in instances when patients receive intrathecal morphine for a planned laparoscopic surgical procedure which is converted to laparotomy intraoperatively. This retrospective single-centre cohort study aimed to evaluate outcomes after intrathecal morphine in patients undergoing open colorectal surgery.

METHODS

All patients who received intrathecal morphine before open colorectal surgery at a secondary hospital in Sweden between 2016 and 2020 were included. Routinely collected data from the Swedish PeriOperative Registry and patients' medical records were reviewed, and data regarding postoperative outcomes including the incidence of postoperative rescue thoracic epidural analgesia and adverse events were extracted.

RESULTS

In total, 108 patients were included with a median age of 74 years. Four patients (4%) received rescue thoracic epidural analgesia postoperatively, and the median hospital length of stay was 8 days. The median intrathecal morphine dose was 200 µg. Respiratory complications occurred in two patients (2%).

CONCLUSION

The incidence of rescue thoracic epidural analgesia after intrathecal morphine in open colorectal surgery was low, and there were few adverse events. The results suggest that intrathecal morphine could be a viable alternative for postoperative pain management in open colorectal surgery.

Perioperative enhanced recovery program implementation improves clinical outcomes in patients with ulcerative colitis after total proctocolectomy with ileal pouch-anal anastomosis

BACKGROUND

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely regarded as a definitive surgical option for managing ulcerative colitis (UC). Enhanced recovery programs (ERP) have shown potential in better outcomes following surgery; however, their perioperative benefits in UC patients undergoing IPAA remain insufficiently investigated.

METHODS

This study included UC patients who underwent IPAA between January 2008 and September 2023 across multiple affiliated centers within the China UC Pouch Center Union. Key outcomes analyzed included postoperative complications and long-term quality of life (QOL), assessed via the comprehensive complication index (CCI) and Cleveland Global Quality of Life (CGQL) instrument.

RESULTS

A total of 216 patients were included, with a median follow-up of 8.0 years (interquartile range, 4.0-11.0 years); 62 patients underwent comprehensive ERP. Results indicated that ERP implementation significantly lowered CCI scores (p = 0.036), reduced the incidence of severe complications (CCI > 26.2, p = 0.019), shortened hospital stays (p = 0.046), and improved long-term QOL (p < 0.001). Non-adherence to ERP emerged as an independent risk factor for severe postoperative complications (odds ratio, 3.195; 95% confidence interval, 1.332-7.664; p = 0.009) and impaired QOL (odds ratio, 3.222; 95% confidence interval, 1.462-7.101; p = 0.004).

CONCLUSION

Our study provided supporting evidence for the application of perioperative ERP in a specific homogeneous cohort of UC patients undergoing IPAA to further improve clinical outcomes for them.

Impact of Fascial Plane Block on Postoperative Length of Stay and Opioid Use Among Colectomy Patients Within an Established Enhanced Recovery After Surgery Program: A Retrospective Cohort Study

Background

Use of fascial plane blocks is increasing yet their impact on hospital length of stay (LOS) and opioid use within the context of an enhanced recovery after surgery (ERAS) pathway has been inconclusive. We address this gap by examining the impact of fascial plane blocks on postoperative LOS and opioid use for colorectal surgical procedures in a hospital setting with a robust ERAS program.

Methods

This is a retrospective cohort study using electronic health record data from a large, integrated health care delivery system with an established ERAS program in Northern California. Patients include adults who underwent non-emergent laparoscopic (n=5496) or non-laparoscopic (n=708) colectomy surgery from January 1, 2015 to May 20, 2021. The main exposure was type of anesthesia: general with long-acting fascial plane block, general with short-acting fascial plane block, or general only. Outcomes included postoperative LOS and average daily morphine milligram equivalents (MME) up to three days post-surgery.

Results

Most patients were older than age 50 (86% laparoscopic; 83% non-laparoscopic), female (52% laparoscopic; 58% non-laparoscopic), and non-Hispanic White (64% laparoscopic; 62% non-laparoscopic). In LOS adjusted models for laparoscopic and non-laparoscopic surgery, there was no significant difference for LOS with general with long-acting fascial plane block or with general with short-acting fascial plane block, compared to general only. In MME adjusted models for laparoscopic surgery, general with short-acting fascial plane block was associated with higher MME compared with general only (RE: 1.14,[95% CI: 1.03-1.25], p-value=0.01). However, in non-laparoscopic surgery, general with long-acting fascial plane block was associated with lower MME (RE: 0.63, [95% CI: 0.42-0.93], p-value=0.02), compared with general only.

Conclusion

Fascial plane blocks did not impact postoperative LOS in either surgical group but long acting resulted in lower overall postoperative opioid use for non-laparoscopic surgery.

Length of stay after colorectal surgery in Italy: the gap between "fit for" and "actual" discharge in a prospective cohort of 4529 cases

BACKGROUND

It is common to observe a gap between the day on which the discharge criteria are reached and the actual day of discharge after colorectal surgery. The aim of this study is to understand the reasons for this difference and its clinical impact on the overall length of stay (LOS).

METHODS

All patients enrolled in the prospective iCral3 study were analyzed regarding any difference and reason between the "fit for discharge" (FFD) and "actual discharge" (AD) dates. The association between the gap and the LOS in the whole population was then assessed through a multivariate regression model including other confounding variables.

RESULTS

The analysis included 4529 patients, with a median [IQR] LOS of 6 [4-8] days. The median [IQR] LOS was 6 [4-8] days in the no-gap group (3,910 patients, 86.3%), significantly lower (p < .001) than 7 [6-10] days in the gap group (619 patients, 13.7%). Among the gap reasons, the "need for postoperative rehabilitation" compared to "not willing to return home" and "social constraints" was associated with the longest LOS (9 [6.0-12.5] days, p < 0.001 vs other reasons). The existence of the gap independently determined a 2.3-day lengthening of LOS.

CONCLUSIONS

Among other factors, the gap between FFD and AD had an independent impact on LOS. The most frequent reasons for this gap were "not willing to return home" and "social constraint", while the "need for postoperative rehabilitation" had the greater clinical impact.

The impact of indocyanine green fluorescence angiography (ICG-FA) on anastomotic leak rates and postoperative outcomes in colorectal anastomoses: a systematic review

BACKGROUND

Anastomotic leak (AL) is a major complication in colorectal surgery, significantly contributing to perioperative morbidity and mortality. Among strategies to prevent AL, Indocyanine Green Fluorescence Angiography (ICG-FA) has emerged as a promising method for assessing bowel perfusion intraoperatively. This systematic review evaluates the impact of ICG-FA on AL rates and other postoperative outcomes following colorectal anastomoses.

METHODS

A systematic search was conducted in PubMed, PubMed Central, MEDLINE, and Google Scholar, following PRISMA guidelines. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and retrospective cohort studies comparing ICG-FA to controls in adult patients undergoing colorectal resections and anastomoses. Data on AL rates, intraoperative characteristics, and postoperative outcomes were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool.

RESULTS

Sixteen studies (12 retrospective, 1 prospective, and 3 RCTs) involving 3231 patients (1562 ICG-FA and 1669 controls) were included. AL rates were significantly lower in the ICG-FA group (5.18%) compared to controls (11.50%) (p < 0.01). ICG-FA influenced surgical plans in 16.31% of cases. Operative time and ileostomy formation rates were comparable between groups. Reoperation, ileus, and wound infection rates showed minimal differences. Mortality rates were low in both groups (ICG-FA: 0.55%, control: 0.51%).

CONCLUSION

ICG-FA significantly reduces AL rates without increasing operative time or postoperative complications. This technique provides a reliable and safe assessment of bowel perfusion, supporting its integration into colorectal surgery protocols. Further high-quality RCTs are needed to confirm these findings and optimise its application.

The Impact of ERAS and Multidisciplinary Teams on Perioperative Management in Colorectal Cancer

INTRODUCTION

The Enhanced Recovery After Surgery (ERAS) protocol, a comprehensive multimodal approach, aims to mitigate surgical stress, expedite recovery, and improve postoperative outcomes. Its implementation has notably advanced perioperative care in colorectal cancer surgeries. Integrating ERAS with multidisciplinary collaboration, involving surgery, anesthesia, nursing, and nutrition, may further enhance patient outcomes, making it a significant focus in clinical practice.

METHODS

This study assessed the effectiveness of integrating the ERAS model with multidisciplinary collaboration during the perioperative period in colorectal cancer patients. A total of 117 patients scheduled for elective surgery at Haiyan People's Hospital between August 2023 and April 2024 were randomly assigned to either a control group (n = 59), receiving traditional care, or an experimental group (n = 58), receiving ERAS-based multidisciplinary care. Key outcomes related to postoperative rehabilitation were evaluated.

RESULTS

Patients in the ERAS group demonstrated significantly shorter hospital stays, quicker catheter removal, and earlier mobilization compared to the control group (P < 0.0001 for all). Additionally, the ERAS group exhibited reduced postoperative inflammatory responses, as indicated by significantly lower interleukin-6 levels on the first postoperative day (P = 0.0247). The quality of life was significantly higher in the ERAS group (P < 0.05). Furthermore, the ERAS group incurred lower total hospitalization expenses than the control group (P = 0.0011).

CONCLUSION

These findings confirm the benefits of the ERAS protocol in enhancing postoperative recovery in colorectal cancer surgeries. The study highlights the importance of a multidisciplinary approach in optimizing patient outcomes and reducing the burden on hospital resources.

SELective defunctioning Stoma Approach in low anterior resection for rectal cancer (SELSA): Protocol for a prospective study with a nested randomized clinical trial investigating stoma-free survival without major LARS following total mesorectal excision

AIM

Accumulated data suggest that routine use of defunctioning stoma in low anterior resection for rectal cancer may cause kidney injury, bowel dysfunction and a higher risk of permanent stomas. We aim to study whether avoidance of a diverting stoma in selected patients is safe and reduces adverse consequences.

METHODS

SELSA is a multicentre international prospective observational study nesting an open-label randomized clinical trial. All patients with primary rectal cancer planned for low anterior resection are eligible. Patients operated with curative intent, aged <80 years, with an American Society of Anaesthesiologists' fitness grade I or II, and a low predicted risk of anastomotic leakage are eligible to 1:1 randomization between no defunctioning stoma (experimental arm) or a defunctioning stoma (control arm). The primary outcome is the composite measure of 2-year stoma-free survival without major low anterior resection syndrome (LARS). Secondary outcomes include anastomotic leakage, postoperative mortality, reinterventions, stoma-related complications, quality of life measures, LARS score, and permanent stoma rate. To be able to state superiority of any study arm regarding the main outcome, with 90% statistical power and assuming 25% attrition, we aim to enrol 212 patients. Patient inclusion will commence in the autumn of 2024.

CONCLUSION

The SELSA study is investigating a tailored approach to defunctioning stoma use in low anterior resection for rectal cancer in relation to the risk of anastomotic leakage. Our hypothesis is that long-term effects will favour the selective approach, enabling some patients to avoid a defunctioning stoma.

TRIAL REGISTRATION

Swedish Ethical Review Authority approval (2023-04347-01, 2024-02418-02 and 2024-03622-02), Regional Ethics Committee Denmark (H-24014463), and ClinicalTrials.gov (NCT06214988).

Enhanced Recovery After Surgery Pathways and Obstetric Anesthesia: A Bibliometric Analysis

As enhanced recovery after surgery (ERAS) pathways are being used exceedingly all over the world, research on ERAS and obstetric anesthesia is expanding. The necessity for uniform guidelines is highlighted by the notable regional and institutional differences in ERAS pathway implementation. Bibliometric research can identify these differences, which promotes a more consistent use of evidence-based procedures. The present bibliographic analysis reviewed 866 documents from the Scopus database using the keywords "enhanced recovery after surgery, ERAS, and Obstetrics Anesthesia." An increased number of articles were added to the database from 2017, with 175 articles in 2024. VOSviewer software (version 1.6.20, Leiden University, Netherlands) was used to investigate the various aspects of bibliometric analysis. The five aspects that were analyzed were co-authorship, co-occurrence, citation, bibliographic coupling, and co-citation. The United States of America had the maximum number of articles, citations, organizations, co-authorship, and co-citation with other authors, organizations, and countries. In the citations category, Gustafsson had the maximum number of citations in documents, and Anesthesia and Analgesia had the maximum number of citations in a journal. A thorough summary of the development of the field of ERAS in obstetric anesthesia can be found in this bibliometric analysis. This analysis has identified important research contributions, significant authors, and new trends by looking at publications, citations, and collaborations. Future research, policymaking, and clinical practice could benefit greatly from this information.

Improving Enhanced Recovery after Surgery (ERAS): The Effect of a Patient-Centred Mobile Application and an Activity Tracker on Patient Engagement in Colorectal Surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) protocol improved perioperative colorectal care. Although the protocol is firmly implemented across hospital settings, there are benefits to gain by actively involving patients in their recovery. The main objective of this study was to investigate whether compliance with selected items in the ERAS protocol could further improve by using a patient-centred mobile application.

METHOD

This multicentre, randomised controlled trial was conducted between October 2019 and September 2022. Patients aged 18 years or older who underwent elective colorectal surgery, and in possession of a smartphone were included. The intervention group used a mobile application combined with an activity tracker to be guided and supported through the ERAS pathway. The control group received standard care and wore an activity tracker to monitor their daily activities. The primary outcome was overall compliance with selected active elements of the ERAS protocol.

RESULTS

In total, 140 participants were randomised to either the intervention (n = 72) or control group (n = 68). The use of the ERAS App demonstrated a significant improvement in overall compliance by 10%, particularly in early solid food intake by 42% and early mobilization by 27%. Postoperative or patient reported outcomes did not differ between groups.

CONCLUSION

The smartphone application 'ERAS App' is able to improve adherence to the active elements of the ERAS protocol for colorectal surgery. This is an important step towards optimizing perioperative care for colorectal surgery patients and enabling patients to optimize being in control of their own recovery. Trial registration: ERAS APPtimize, NTR7314 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON29410).

Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial

Importance

Evidence suggests that prophylactic abdominal drainage after gastrectomy for cancer may reduce postoperative morbidity and hospital stay but this evidence comes from small studies with a high risk of bias. Further research is needed to determine whether drains safely meet their primary purpose of identifying and managing postoperative intraperitoneal collections without the need for reoperation or additional percutaneous drainage.

Objective

To determine whether avoiding routine abdominal drainage increased postoperative invasive procedures.

Design, Setting, and Participants

The Abdominal Drain in Gastrectomy (ADIGE) Trial was a multicenter prospective randomized noninferiority trial. Enrollment spanned from December 2019 to January 2023. Follow-up evaluations were completed at 30 and 90 days. Eleven centers within the Italian Research Group for Gastric Cancer, encompassing both academic medical centers and community hospitals, were included. Patients with gastric cancer undergoing subtotal or total gastrectomy with curative intent were eligible, excluding those younger than 18 years, with serious comorbidities, or undergoing procedure types outside the scope of the study. Of 803 patients assessed for eligibility, 404 were randomized and 390 were included in final analyses.

Interventions

Patients were randomized 1:1 into prophylactic drain or no drain arms.

Main Outcomes and Measures

The primary end point was a modified intention-to-treat (mITT) analysis measuring reoperation or percutaneous drainage within 30 postoperative days. The null hypothesis was rejected when the 90% CI upper limit of the proportion difference did not exceed 3.56%. The calculated sample size to achieve 80% power with a 10% dropout rate was 404 patients (202 in each group). Surgeons and patients were blinded until gastrointestinal reconstruction.

Results

Of the 404 patients randomized 226 (57.8%) were male; the median (IQR) age was 71 (62-78) years. Intraoperative identification of nonresectable disease occurred in 14 patients, leading to their exclusion from the study, leaving 390 patients. In the mITT analysis, 15 patients (7.7%) in the drain group needed reoperation or percutaneous drainage by postoperative day 30 vs 29 (15%) in the no drain group, favoring the drain group (difference, 7.2%; 90% CI, 2.1-12.4; P = .02). Of note, the difference in the primary composite end point was entirely due to a similar difference in reoperation (5.1% in the drain group vs 12.4% in the no drain group; P = .01). Drain-related complications occurred in 4 patients.

Conclusions and Relevance

The findings of this study indicate that refraining from prophylactic drain use after gastrectomy heightened the risk of postoperative invasive procedures, discouraging its avoidance. Future studies identifying high-risk groups could optimize prophylactic drainage decisions.

Trial Registration

ClinicalTrials.gov Identifier: NCT04227951.

Bibliometric Analysis on Cholecystectomy Surgery in the Nursing Field

PURPOSE

This study aimed to bibliometrically examine nursing publications regarding cholecystectomy surgery.

DESIGN

The study is a bibliometric analysis.

METHODS

The study was conducted in the Web of Science database. The keywords "cholecystectomy AND nursing" were used during the scanning. The data were evaluated in quantitative aspects.

FINDINGS

In the study, 481 publications were identified, publications were made between 1987 and 2023, the average number of years since the release of the publication was 10.2, and the annual increase rate was 8.19%. The most active country was the United States, and the journal most often published in was the "Journal of Perianesthesia Nursing." In the last 3 years, the themes of "meta-analysis, complication, pain, anxiety, quality of life" have been trending, the most working and continuing to develop our "laparoscopic cholecystectomy" and "pain" themes, and the leading theme in the field was "anxiety".

CONCLUSIONS

This study is the first bibliometric study examining nursing studies on cholecystectomy and provides a comprehensive overview of cholecystectomy and nursing issues over 36 years. In quantitative data, it was concluded that although studies in this field have a long history, the number of publications is low, and the annual growth rate is low. According to the quantitative evaluation results, it was found that the most studied topic in this field was laparoscopic cholecystectomy and pain, minimally invasive intervention and perioperative period topics remained isolated, and computerized tomography and gallbladder themes were among the newly emerging themes.

Assessment of the adherence to perioperative nutritional care protocols in Brazilian hospitals: The PreopWeek study

OBJECTIVES

The study (PreopWeek) aimed to assess the perioperative nutritional care for major surgical patients in Brazilian hospitals, focusing on adherence to emerging multimodal protocols like Enhanced Recovery After Surgery and Acceleration of Total Postoperative Recovery.

METHODS

An observational cross-sectional study was conducted in Brazilian hospitals enrolled voluntarily from June 19 to June 23, 2023 (convenience sample). Data were collected through patient interviews and medical records review.

RESULTS

Data from 219 patients up to the fifth postoperative day or postoperative discharge across 24 hospitals were analyzed. Only three hospitals (12.5%) had established institutional perioperative protocols. Most of the patients were female (60.3%) and over 60 y old (81.7%) and underwent gastrointestinal (34.7%) or orthopedic (33.3%) surgeries. General and nutritional preoperative counseling was provided to a respective 82.2% and 62.6% of the patients. Only 25.7% of the patients had preoperative fasting for up to 3 h, and 28.8% received carbohydrate-rich supplements. Immunonutrition was not received by 43.8% at any point. Although most started postoperative refeeding within 24 h (81.7%), 39.4% started with a liquid diet and 70.6% reported postoperative immobilization in the first 24 h. Notable differences were observed between hospitals with and without protocols. Hospitals with institutional protocols reported significantly more preoperative exercises and nutritional counseling and higher adherence rates for all the perioperative protocols.

CONCLUSIONS

Our study demonstrates a lack of adherence to the multimodal protocols, even in hospitals with institutional protocols. Future educational programs are necessary to improve this result.

Effects of enteral immunonutrition in laparoscopic versus open resections in colorectal cancer surgery: A meta-analysis of randomised controlled trials

INTRODUCTION

Immunonutrition (IMN) modulates the activity of the immune system. However, the effects of IMN on cancer patients following colorectal surgery is still lacking. We performed a systematic review and meta-analysis to evaluate the outcomes of IMN in patients undergoing laparoscopic versus open colorectal surgery.

METHODS

A systematic search of multiple electronic data sources was conducted in accordance with PRISMA guidelines and included MEDLINE via PubMed, EMBASE, Scopus, and Web of Science. All eligible studies reporting comparative outcomes of immunonutrition in colorectal surgery were included. Subgroup analysis of outcomes of interest was performed and data were analysed using Review Manager (RevMan) Version 5.4.1.

RESULTS

Nine randomised controlled trials (RCTs) were identified. The final pooled analysis included 1199 patients (592 IMN group and 592 control group). Of these, 55.3 % (655/1184) had open colorectal surgery (OG) and 44.7 % (529/1184) underwent laparoscopic colorectal surgery (LG). IMN reduced the risk of wound infection significantly in the OG [risk ratio (RR) 0.48, 95 % confidence interval (CI) 0.32 to 0.72; p = 0.0005)] and the open and laparoscopic group (OLG) [RR 0.33, 95 % CI 0.15 to 0.76; p = 0.008]. Moreover, IMN was also associated with a significantly shorter length of hospital stay (MD - 2.37 days, 95 % CI - 3.39 to -1.36; p < 0.0001) in the OG. Other post-operative morbidities (anastomotic leak and ileus) and mortality outcomes in the OG, LG, and OLG were comparable.

CONCLUSIONS

Pre-operative IMN could reduce the wound infection rate and shorten length of hospital stay in patients following elective colorectal surgery. The benefit of these improved clinical outcomes could be further evaluated with a cost-benefit analysis. IMN should be recommended as nutritional adjunct in the Enhanced Recovery after Surgery (ERAS) pathway following colorectal surgery.

Impact of tranexamic acid use in total hip replacement patients: A systematic review and meta-analysis

Purpose

Tranexamic acid (TXA) dose in the context of primary complete hip replacements (THA) is still a hot debate about the best way to administer TXA. The need to select the most efficient and secure TXA dosing regimen, taking into account elements like perioperative bleeding, postoperative complications, and patient outcomes, has been emphasized by numerous studies. Improving clinical procedures and the general efficacy and safety of employing TXA in THA surgeries requires addressing this ongoing debate.

Methods

For this systematic review, We looked at the safety and efficacy of administering TXA intravenously (iTXA) and topically (tTXA) during THA. A thorough search turned up ten randomized controlled trials with 1295 individuals. Parameters evaluated included blood loss, Hb level on the day following surgery, transfusion rates, and drainage volume.

Results

Strategies had comparable impacts on deep vein thrombosis occurrences and wound complications. iTXA produced considerably less intraoperative blood loss (WMD = -12.687), concealed blood loss (WMD = 14.276), and the greatest hemoglobin drop (WMD = -0.400) when compared to tTXA.

Conclusion

Both administration techniques were secure and efficient in primary THA, although iTXA showed superior results in lowering blood loss and Hb decline.

Modified Thoracoabdominal Nerves Block Through Perichondral Approach: A Systematic Review and Meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to investigate the postoperative analgesic efficacy and safety of the modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) in abdominal surgeries.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched electronic databases to identify relevant studies comparing M-TAPA with conventional analgesic techniques. The primary outcome was the requirement for rescue analgesia at 12 and 24 hours postsurgery. Secondary outcomes included the 11-point numerical rating scale pain scores at 0, 1, 2, 4, 6, 8, 12, and 24 hours following surgery, global quality of recovery scores, and postoperative adverse events.

FINDINGS

Five randomized controlled trials involving 308 patients were analyzed. M-TAPA showed no significant difference in the requirement for rescue analgesia at 12 hours (relative risk [RR]: 0.87; 95% confidence interval [CI]: 0.62, 1.22; P = .424; I2 = 40.7%; Ph = .185) and 24 hours (RR: 0.67; 95% CI: 0.22, 1.99; P = .252; I2 = 90.3%; Ph < .001) postsurgery compared to non-M-TAPA. No significant differences in numerical rating scale pain scores or global quality of recovery scores were found between the two groups (all P < .05). However, M-TAPA was associated with a lower occurrence of nausea (RR: 0.37; 95% CI: 0.22, 0.68; P < .001; I2 = 0%; Ph = .834), vomiting (RR: 0.32; 95% CI: 0.17, 0.62; P < .001; I2 = 0%; Ph = .884), and itching (RR: 0.38; 95% CI: 0.21, 0.70; P = .002; I2 = 0%; Ph = .826).

CONCLUSIONS

There was no significant difference in analgesic efficacy and safety between M-TAPA and non-M-TAPA techniques.

Impact of Multi-Institutional Enhanced Recovery after Surgery Protocol Implementation on Elective Colorectal Surgery Outcomes

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols aim to improve surgical patient outcomes, although their effectiveness may vary. This study assessed the impact of multi-institutional ERAS implementation on postoperative morbidity in patients undergoing elective colorectal surgery.

STUDY DESIGN

We conducted a multicenter retrospective cohort study using the American College of Surgeons NSQIP database from 2012 to 2020. We analyzed patient outcomes before (2012 to 2014) and after (2015 to 2020) ERAS implementation across 4 hospitals. Multivariable logistic regression was used to determine the impact of ERAS program on certain outcomes.

RESULTS

A total of 8,930 cases were analyzed: 3,573 in the pre-ERAS and 5,357 in the ERAS cohort. The ERAS cohort demonstrated significant reductions in superficial surgical site infection (SSI; 7.5% vs 2.5%, p < 0.001), deep SSI (0.6% vs 0.2%, p = 0.016), urinary tract infection (3.3% vs 1.5%, p < 0.001), pulmonary embolism (0.7% vs 0.4%, p = 0.022), deep vein thrombosis (1.4% vs 0.9%, p = 0.020), sepsis (3.0% vs 2.1%, p = 0.006), and other complications. Median length of stay decreased from 5 to 4 days (p < 0.001), and 30-day readmission rate dropped from 11.3% to 9.8% (p = 0.022). Overall, ERAS implementation was associated with a 35% decrease in the odds of all 30-day complications (odds ratio 0.65, 95% CI 0.59 to 0.73). There was no effect on 30-day (p = 0.962) or overall mortality rates (p = 0.732).

CONCLUSIONS

A standardized ERAS protocol, used across multiple institutions, significantly improves elective colorectal surgery outcomes, reducing complications, length of hospital stay, and readmissions. These findings support the broader implementation of ERAS to enhance patient care and reduce healthcarecosts.

The Role of Patient-Controlled Epidural Analgesia in the Short-Term Outcomes of Laparoscopic-Assisted Gastrectomy in Elderly Gastric Cancer Patients

INTRODUCTION

Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) constitute two major advances in pain management after major abdominal surgery. However, the role of PCIA or PCEA has not been particularly studied in elderly patients with gastric cancer. The aim of this study is to make a comparison between PCIA and PCEA in terms of their performance on short-term outcomes in elderly patients undergoing laparoscopic-assisted gastrectomy.

METHODS

This single-center, retrospective study included 254 elderly patients (≥70 y) who underwent laparoscopic radical gastrectomy for gastric cancer. Patients received either general anesthesia combined with epidural anesthesia followed by PCEA (PCEA group, n = 123) or general anesthesia alone followed by PCIA (PCIA group, n = 131). The primary endpoint was pain intensity-tested using a 100-mm visual analog scale on postoperative days 1, 2, and 3. Demographics, comorbidities, perioperative data, postoperative short-term outcomes, and analgesia-related side effects were also assessed.

RESULTS

The visual analog scale scores at rest were lower in the PCEA group compared to the PCIA group on postoperative day 1, 2, and 3 (27.8 ± 13.9 versus 33.1 ± 15.0, P = 0.004; 25.2 ± 11.3 versus 30.1 ± 14.3, P = 0.002; 16.9 ± 7.1 versus 20.9 ± 9.5, P < 0.001, respectively). The postoperative hospital stay was shorter in the PCEA group than in the PCIA group (11 versus 12 d, P = 0.018). The times to postoperative first flatus, semifluid diet, independent ambulation, and tracheal extubation after surgery in the PCEA group were significantly shorter than in the PCIA group. Overall morbidity, mortality, hospital readmission rate, and reoperation rate were not significantly different between the two groups. Regarding side-effects related to analgesia, there were no significant differences in terms of the rates of postoperative nausea and vomiting, urinary retention, or oxygen saturation <90% between the two groups. However, PCEA was associated with a higher incidence of postoperative hypotension compared to PCIA (10.6% versus 3.8%, P = 0.036).

CONCLUSIONS

In elderly patients undergoing laparoscopic radical gastrectomy, epidural anesthesia and analgesia may convey superior pain relief, faster restoration of gastrointestinal motility, and shorter hospitalization.

Enhanced recovery after surgery society's recommendations for liver surgery reduces non surgical complications

Enhanced Recovery after Surgery (ERAS) is a multimodal approach to improve surgical outcome and has been implemented in many fields of surgery in an international scale. The aim of this study was to evaluate the effect of the Enhanced Recovery after Surgery (ERAS) society recommendations in liver surgery and the impact on general and surgery-related complications. 1049 patients who underwent liver surgery from July 2018 to October 2023 were included. The ERAS program strictly followed the official ERAS society recommendations. As a control group (Non-ERAS) 90 patients were treated according to the clinic standard, while 959 patients were treated according within the ERAS measures. After propensity score (PSM) matching 87 Non-ERAS and 258 ERAS patients were analyzed by complications and cumulative sum analysis (CUSUM). ERAS implementation resulted in a significant decrease in general complications (control 27.6% vs. ERAS 16.3%, p = 0.033), largely attributed to a reduction in infection-related complications (control 20.7% vs. ERAS 9.7%, p = 0.007). When examining surgery-related complications no significant disparities were observed (control 17.2% vs. ERAS 17.1%, p = 0.968). The CUSUM analysis of general and non-surgical complications showed that the full effect of the ERAS program only became apparent after several years. Moreover, adherence increased over time consecutively from 62.5 to 72.5% in 4 years. The ERAS society recommendations for liver surgery reduced general complications but did not have any effect on surgery related complications. The effect of the ERAS program progressively improved over the years, highlighting the need for continuous effort to maintain and further enhance outcomes.

Effect of enhanced recovery after surgery on older patients undergoing transvaginal pelvic floor reconstruction surgery: a randomised controlled trial

BACKGROUND

Prospective trial evidence is lacking regarding the application of enhanced recovery after surgery (ERAS) in transvaginal pelvic floor reconstruction surgery among older patients. Our study aimed to investigate whether implementing the ERAS protocol could enhance post-operative recovery in this patient population.

METHODS

Older patients undergoing elective transvaginal pelvic floor reconstruction surgery were randomly assigned to either the ERAS group or the conventional group. The primary outcome was post-operative length of stay (LOS). The secondary outcomes encompassed other post-operative recovery metrics, post-operative pain within 30 days, the occurrence of complications, the peri-operative blood test and cognitive function.

RESULTS

A cohort of 100 patients was enrolled. Implementation of the ERAS protocol significantly reduced the duration of post-operative LOS (74.00 (69.00, 96.00) vs. 65.00 (59.00, 78.25) h, P < 0.01). Additionally, the ERAS protocol significantly reduced the duration of the first oral intake post-operatively (5.00 (2.50, 7.00) vs. 3.00 (2.00, 4.00) h, P = 0.01), and reduced rest and movement-related pain within 48 h post-operatively, effects that persisted through the 7-day follow-up period. It also shortened the duration of post-operative laryngeal mask airway support and promoted opioid-sparing. Moreover, the incidence and severity of post-operative nausea and vomiting (PONV) were significantly lower in the ERAS group compared to the conventional group at 12 h post-operatively.

CONCLUSIONS

Implementation of the ERAS protocol can expedite post-operative recovery in older patients undergoing transvaginal pelvic floor reconstruction surgery, achieve opioid-sparing, alleviate pain post-operatively, and decrease the incidence of complications.

TRIAL REGISTRATION

This study was retrospectively registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2400084608). The date of first registration was 21/05/2024.

Effectiveness of rehabilitation interventions in patients with colorectal cancer: an overview of systematic reviews

OBJECTIVE

To evaluate existing evidence from published systematic reviews for the effectiveness and safety of rehabilitation interventions in adult patients with colorectal cancer.

METHODS

A comprehensive literature search was conducted using medical/health science databases up to October 2024. Bibliographies of pertinent articles, journals, and grey literature were searched. Three reviewers independently selected potential reviews, assessed methodological quality, and graded the quality of evidence for outcomes using validated tools.

RESULTS

Sixty systematic reviews (761 randomized controlled trials) evaluated 5 categories of rehabilitation interventions. Over half of the included reviews (n = 31) were of moderate-high quality. The findings suggest: moderate-quality evidence for exercise interventions for improving physical fitness and quality of life; high-quality evidence for nutritional interventions in reducing postoperative infections; high-quality evidence for multimodal prehabilitation for improved preoperative functional capacity; moderate-quality evidence for nutritional interventions for improving humoral immunity, reducing inflammation, and length of stay; moderate-quality evidence for acupuncture in improving gastrointestinal functional recovery; psychosocial interventions in improving short-term quality of life and mental health, and lifestyle interventions for improved quality of life.

CONCLUSION

Rehabilitation interventions yielded positive effects across multiple outcomes. However, high-quality evidence is still needed to determine the most effective rehabilitation approaches for patients with colorectal cancer.

Transversus abdominis plane block in minimally invasive colon surgery: a multicenter three-arm randomized controlled superiority and non-inferiority clinical trial

BACKGROUND AND OBJECTIVES

The transversus abdominis plane (TAP) block is the most widely used abdominal field block in colorectal surgery with a postoperative enhanced recovery pathway. We aimed to determine whether the laparoscopic-assisted and ultrasound-guided TAP (US-TAP) blocks provide superior pain relief compared with placebo. We separately investigated whether the laparoscopic-assisted technique was non-inferior to the ultrasound-guided technique in providing pain relief, with a non-inferiority margin of 10 mg morphine dose equivalents.

METHODS

340 patients undergoing elective minimally invasive colon surgery were randomly allocated to one of three groups: (1) US-TAP block, (2) laparoscopic-assisted TAP (L-TAP) block, or (3) placebo. Superiority and non-inferiority were tested for the primary outcome: 24-hour postoperative morphine equivalent consumption. Secondary outcomes, including patient-reported quality of recovery, were included in the superiority analysis.

RESULTS

127 patients were included in each block group and 86 in the placebo group. The US-TAP block was no different from placebo at -1.4 mg morphine (97.5% CI -6.8 to 4.0 mg; p=0.55). The L-TAP block was superior to placebo at -5.9 mg morphine (97.5% CI -11.3 to -0.5 mg; p=0.01) and non-inferior to the US-TAP block at -4.5 mg morphine (98.75% CI -10.0 to 1.1 mg).

CONCLUSION

The L-TAP block was superior to placebo and non-inferior to the US-TAP block. However, neither met our predetermined estimate of the minimal clinically important difference of 10 mg morphine.

TRIAL REGISTRATION NUMBER

NCT04311099.

Changes in nutritional management after gastrointestinal cancer surgery over a 12-year period: a cohort study using a nationwide medical claims database

BACKGROUND

Nutritional management in patients after gastrointestinal cancer surgery has changed throughout the 2000s. However, its evolution has not been formally studied. This study aimed to evaluate changes in nutritional management using real-world data.

METHODS

Patient data from 2011 to 2022 were extracted from a nationwide medical claims database. Patients were divided into four groups based on their year of hospital admission: period I, 2011-2013; II, 2014-2016; III, 2017-2019; IV, 2020-2022. For each period, feeding routes in all patients and prescribed doses of parenteral energy and amino acids in fasting patients during postoperative days (POD) 1-7 were determined. The results of the four different periods were compared using statistical trend tests.

RESULTS

The study cohort was comprised of 365,125 patients. During POD 1-3, the proportion of patients administered any oral intake increased over time (I, 40.3%; II, 47.1%; III, 49.4%; IV, 54.2%; P < 0.001), while that of patients receiving parenteral nutrition (PN) decreased (I, 60.1%; II, 55.0%; III, 50.3%; IV, 45.5%; P < 0.001). Of 19,661 patients with PN alone (i.e., neither oral intake nor enteral nutrition) during POD 1-7, the median (interquartile range) prescribed doses on POD 7 of energy (kcal/kg) [I, 15.3 (10.3-21.9); II, 13.9 (8.4-20.0); III, 13.2 (7.7-19.2); IV, 12.9 (7.0-18.7); P < 0.001] and amino acids (g/kg) [I, 0.65 (0.30-0.94); II, 0.58 (0.24-0.89); III, 0.56 (0.00-0.86); IV, 0.56 (0.00-0.87); P < 0.001] both decreased over time.

CONCLUSION

From 2011 to 2022, more patients who underwent gastrointestinal cancer surgery in Japan were administered early oral intake, while fewer patients were administered early PN. Overall, the energy and amino acid doses prescribed in PN were far below the guideline recommendations.

The Effect of Early Mobilization on Pain and Mobility Levels in Patients Undergoing Total Knee Prosthesis

PURPOSE

This study was conducted to determine the effect of early mobilization on pain and mobility levels in individuals undergoing total knee arthroplasty.

DESIGN

Randomized controlled clinical trial.

METHODS

This study was carried out in the orthopedic and traumatology department of a public hospital in Turkey. The data were collected between September 2022 and June 2023. The study sample consisted of 68 patients, 34 in the intervention group and 34 in the control group. Patient Information Form, Brief Pain Inventory, Patient Mobility Scale, and Observer Mobility Scale were used as data collection tools.

FINDINGS

The decrease in the "current pain" 20th-hour value was significant compared to the "current pain" 8th-hour value in patients in the intervention group. In the control group, the mean value of the Patient Mobility Scale at the 20th hour was significantly higher than the intervention group. In the intervention group, the pain and difficulty measurements during the movements of turning from side to side in the bed, sitting on the edge of the bed, standing up on the edge of the bed, and walking in the patient room at the 20th hour decreased significantly compared to the 8th hour. In the control group, the mean of the Observer Mobility Scale at the 20th hour was considerably higher than the intervention group.

CONCLUSIONS

Early mobilization positively affected the patient's pain and mobility levels. An early mobilization protocol should be established and implemented in the postoperative period.

Study protocol of the PRINCESS trial-PReoperative INtermittent fasting versus CarbohydratE loading to reduce inSulin resiStance versus standard of care in orthopaedic patients: a randomised controlled trial

INTRODUCTION

Surgical trauma induces a metabolic stress response, resulting in reduced insulin sensitivity and hyperglycaemia. Postoperative insulin resistance (IR) is associated with postoperative complications, and extended preoperative fasting may further aggravate the postoperative metabolic stress response. Nutritional strategies, such as carbohydrate loading (CHL), have been successfully used to attenuate postoperative IR. Recent evidence suggests that time-restricted feeding (TRF), a form of intermittent fasting, improves IR in the general population, even after a short period of TRF. We hypothesise that TRF, as well as CHL, improve postoperative IR.

METHODS AND ANALYSIS

This open-label, single-centre, randomised controlled trial will compare the effect of short-term preoperative TRF, CHL and standard preoperative fasting on perioperative IR. A total of 75 orthopaedic patients presenting for elective intermediate to major surgery at a Dutch academic hospital will be randomly assigned to a control group (standard preoperative fasting), a TRF group or a CHL group. The primary outcome is postoperative IR, based on the updated homeostasis model assessment of IR, on the first day after surgery. Statistical analyses are performed using Student's t-tests or Mann-Whitney U tests.

ETHICS AND DISSEMINATION

The local medical ethics committee of the Amsterdam UMC, the Netherlands, approved the trial protocol in January 2023 (NL81556.018.22). No publication restrictions apply, and the results of the study will be disseminated through a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05760339.

Effect of Enhanced Recovery after Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction

BACKGROUND

 Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

METHODS

 A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.

RESULTS

 Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.

CONCLUSION

 ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

EARLY REFEEDING AFTER COLORECTAL CANCER SURGERY REDUCES COMPLICATIONS AND LENGTH OF HOSPITAL STAY

BACKGROUND

Multimodal protocols such as Acceleration of Total Postoperative Recovery and Enhanced Recovery After Surgery propose a set of pre- and post-operative care to accelerate the recovery of surgical patients. However, in clinical practice, simple care such as early refeeding and use of drains are often neglected by multidisciplinary teams.

AIMS

Investigate whether early postoperative refeeding determines benefits in colorectal oncological surgery; whether the patients' clinical conditions preoperatively and the use of a nasogastric tube and abdominal drain delay their recovery.

METHODS

Retrospective cohort carried out at the Cascavel Uopeccan Cancer Hospital, including adult cancer patients (age ≥18 years), from the Unified Health System (SUS), who underwent colorectal surgeries from January 2018 to December 2021.

RESULTS

275 patients were evaluated. Of these, 199 (75.4%) were refed early. Late refeeding (odds ratio - OR=2.1; p=0.024), the use of nasogastric tube (OR=2.72; p=0.038) and intra-abdominal drain (OR=1.95; p=0.054) increased the chance of infectious complication. Multivariate analysis showed that receiving a late postoperative diet is an independent risk factor for infectious complications. Late refeeding (p=0.006) after the operation and the placement of an intra-abdominal drain (p=0.007) are independent risk factors for remaining hospitalized for more than five days postoperatively.

CONCLUSIONS

Refeeding early in the postoperative period reduces the risk of infectious complications. Using abdominal drains and refeeding late (>48h) for cancer patients undergoing colorectal surgery are risk factors for hospital stays longer than five days.

Mapping Global Nursing Literature on Enhancing Recovery After Surgery Programs: A Bibliometric Analysis

PURPOSE

To provide a structured macroscopic overview of the characteristics and advances in research related to the Enhancing Recovery after Surgery (ERAS) protocol.

DESIGN

A bibliometric analysis.

METHODS

Web of Science was selected as the search engine for the bibliometric analysis study, and data up to January 25, 2024 were included in the scan. The analysis was conducted using the "biblioshiny" application available in the Bibliometrics R package.

FINDINGS

A total of 769 studies were included in the review between 1991 and 2024. China produced the most publications on the subject, while the United States received the highest number of citations. A total of 213 global collaborations were identified, with the most frequent collaboration being between the United States and Canada (8 collaborations). The author Li K. contributed the most papers and the Journal of Perianesthesia Nursing published the most nursing papers on the topic. "Enhanced recovery" was the most frequently used keyword in the articles. In addition, China led in the number of publications, while the United Kingdom, China, Canada, and Sweden had the highest number of citations of all countries.

CONCLUSIONS

This bibliometric study provided comprehensive information on global trends and hotspots in ERAS protocol care research. Developed countries were the most productive in this area of research. It was noted that publications in this study area did not meet the Lodka and Bradford laws.