Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Bathing with 2% chlorhexidine gluconate versus routine care for preventing surgical site infections after pancreatic surgery: a single-centre randomized controlled trial

OBJECTIVES

The study aims to investigate whether bathing with 2% chlorhexidine gluconate (CHG) reduces the incidence of surgical site infection (SSI) in patients undergoing routine pancreatic surgery.

METHODS

A randomized controlled trial was conducted at a large-volume pancreatic centre between 1 January 2021 and 31 December 2022. Patients undergoing clean-contaminated pancreatic surgery were enrolled and randomized into an intervention arm (bathing with a 2% CHG wipe) and a control arm (routine care, soap, and water). The primary outcome was the incidence of SSI after pancreatic surgery within 30 days.

RESULTS

Overall, 614 patients (intervention arm, 311; control arm, 303) were included in intention-to-treat analysis. In total, 8.8% (54/614) patients developed SSI. The incidence of SSI in the intervention arm was 6.8% (21/311) and 10.9% (33/303) in control arm, and the difference did not reach the level of statistical significance (p 0.070). The time to SSI was significantly extended when patients were in the intervention arm (log-rank test, p 0.047). The intervention did not significantly reduce the incidence of healthcare-associated infection, hospital-acquired pneumonia, and bloodstream infection. No adverse events were observed. However, in the per-protocol analysis among 519 patients, the intervention arm showed a significantly lower incidence of overall SSI than that of those in the control arm (21/272, 7.7% vs. 33/242, 13.4%, p 0.036).

DISCUSSION

Bathing with 2% CHG could potentially reduce the incidence of SSI for the patients scheduled to undergo pancreatic surgery for which further well-designed clinical trials are warranted.

Effect of Enhanced Recovery After Surgery (ERAS) Programs on Perioperative Outcomes in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) programs emerged as a strategy to reduce perioperative morbidity; however, there is currently limited evidence of their clinical efficacy. The objective of this study was to assess the impact of ERAS programs in cardiac surgery on hospital length of stay, mortality, atrial fibrillation, and quality of life.

METHODS

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, encompassing studies on ERAS programs in adult patients undergoing elective cardiac surgery. The effect size and 95% confidence interval (CI) were estimated with a random-effects model. The protocol was preregistered on Open Science Framework.

RESULTS

Eighteen studies (published between 2016 and 2023) comprising 4,469 patients were included in the analysis, of which only one was a randomized controlled trial. The implementation of ERAS was associated with a reduction in hospital stay of 1.24 days (95% CI: -1.67, -0.82, p < 0.001, I2 = 83%). No differences were observed between the groups in mortality (odds ratio: 0.65, 95% CI: 0.28, 1.48, p = 0.3, I2 = 0%), nor in the incidence of atrial fibrillation (odds ratio: 0.77, 95% CI: 0.57, 1.03, p = 0.08, I2 = 17%). A meta-analysis of quality of life was not feasible due to a lack of sufficient data.

CONCLUSIONS

Although ERAS programs were associated with a reduction in hospital stay and no differences in mortality or atrial fibrillation, the quality of the evidence was very low. To recommend the implementation of ERAS programs in cardiac surgery, it is necessary to have randomized studies providing evidence of its efficacy, and studies including quality of life and other patient-centered recovery criteria outcomes.

Home-based prehabilitation: a systematic review and meta-analysis of randomised trials

BACKGROUND

Prehabilitation aims to enhance preoperative functional capacity through exercise, nutrition, and psychological programs. Home-based prehabilitation represents an alternative to hospital prehabilitation, with the advantage of not utilising hospital resources. This review aims to evaluate adherence and clinical effectiveness of home-based prehabilitation.

METHODS

We searched PubMed, Cochrane, and Embase up to October 1, 2024 for randomised controlled trials comparing home-based prehabilitation with standard care. The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes included protocol adherence, and 6-min walking test. We used risk ratios (RR) and mean differences to summarise the results. The risk of bias was assessed using RoB 2 tool.

RESULTS

We included 29 randomised trials for a total of 3508 patients. Median adherence to home-based prehabilitation programs was 82%. Home-based prehabilitation reduced the proportion of patients with postoperative complications (508/1322 [38.4%] vs 578/1335 [43.3%], risk ratio 0.84, 95% confidence interval [CI] 0.72-0.98, P=0.02, I2=44%, low certainty). After home-based prehabilitation, 6-min walking test performance was better compared with control (MD 28.2 m (95% CI 9.5-46.9; P<0.01, I2=48). Preoperative depression (MD -0.65, 95% CI -0.87 to -0.43; P<0.001, I2=0%), postoperative anxiety (MD -0.50, 95% CI -0.75 to -0.25; P<0.001, I2=0%, low certainty) and length of hospital stays (MD -0.32 days, 95% CI -0.61 to -0.03; P=0.03, I2=45%, low certainty) were lower with home-based prehabilitation.

CONCLUSIONS

Home-based prehabilitation reduced the proportion of patients with postoperative complications, but with low certainty of evidence. It also improved preoperative functional capacity, reduced hospital stays, depression and anxiety scores, with good adherence to the intervention.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42024591208).

Interventions to support caregivers of older adults undergoing surgery: A systematic review

INTRODUCTION

Increasing numbers of caregivers provide support to older adults after surgery, which is associated with stress and negative impacts on their health. Our review questions were: METHODS: The databases searched included PubMed, OVID MEDLINE, OVID PsycINFO, EBSCO CINAHL, OVID EMBASE, Web of Science Core Collection, Wiley Cochrane CENTRAL on February 14, 2024. Studies eligible for inclusion were randomized controlled trial (RCT) or quasi-experimental design with control groups, published in English, Dutch, German, French and Persian, included any unpaid caregiver, and the intervention must include a component specifically designed to meet the caregivers' needs.

RESULTS

in total 27,845 were screened and 45 full texts were reviewed. Seven RCTs, two pilot RCTS, and four quasi RCTs were included. Only five interventions had any positive impact and included self-management, telehealth, education and a family-centered care model.

CONCLUSION

Few effective interventions were identified and more engagement with caregivers may identify interventions that better target the caregivers' needs.

PROSPERO REGISTRATION NUMBER

CRD42024519637.

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.

Impact of enhanced recovery after surgery on psychological outcomes in total hip arthroplasty

BACKGROUND

The occurrence of pain catastrophizing, depression, and anxiety is prevalent among patients undergoing primary total hip arthroplasty (THA). The Enhanced Recovery After Surgery protocol (ERAS-P) has demonstrated its efficacy in alleviating peri-operative stress responses in such patients. This study endeavors to explore the influence of ERAS-P on patient satisfaction, as well as the levels of pain catastrophizing, surgery-related anxiety, and depression following primary THA.

HYPOTHESIS

ERAS-P exerts a beneficial influence on patient satisfaction, mitigating pain catastrophizing, and reducing surgery-related anxiety and depression following primary THA.

PATIENTS AND METHODS

Data were retrospectively reviewed for patients who underwent primary THA between 2017 and 2020. Patients in the control group who received usual care were matched in a 1:1 ratio for baseline characteristics to patients in the ERAS-P group who followed ERAS-P. All patients were evaluated and analyzed for pain catastrophizing, depression and anxiety using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS) at postoperative 1 weeks, 6 weeks, 3 months, 6 months and 1 year.

RESULTS

182 patients in the ERAS-P group and 182 in the control group were analyzed using propensity score matching (PSM). Compared to the control group, ERAS-P patients showed significantly higher satisfaction levels (p = 0.002). They also experienced a notable reduction in pain catastrophizing at 1 week, 6 weeks, and 3 months postoperatively (p < 0.05 for all). Anxiety levels decreased markedly at 1 week and 6 weeks (p < 0.001 for both). Depression scores in the ERAS-P group declined significantly at these same time points up to 6 months (p < 0.05 for all). Remarkably, ERAS-P patients exhibited a greater decrease in peri-operative pain catastrophizing and anxiety, accompanied by a faster recovery. However, its effectiveness waned over time, with both groups reporting comparable outcomes within a few months.

DISCUSSION

Patients undergoing THA after adhering to the ERAS-P exhibit a more favorable outcome in improving peri-operative patient-reported depression, anxiety, and pain catastrophizing screenings compared to those following the traditional care scheme. Although these advantages gradually diminished over time, the outcomes for both groups converged to be similar within a few months. Nonetheless, ERAS-P retains its notable advantages for THA patients who grapple with psychological symptoms.

LEVEL OF EVIDENCE

III.

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.

Multimodal Prehabilitation for Gynecologic Cancer Surgery

Surgical treatment is commonly employed to treat patients with gynecologic cancer, although surgery itself may function as a stressor, reducing the patients' functional capacity and recovery. Prehabilitation programs attempt to improve patients' overall health and baseline function prior to surgery, thereby enhancing recovery and lowering morbidity. In recent years, prehabilitation has come to primarily refer to multimodal programs that combine physical activity, nutritional support, psychological well-being, and other medical interventions. However, the specific methods of implementing prehabilitation and measuring its effectiveness are heterogeneous. Moreover, high-level evidence regarding prehabilitation in gynecologic cancer surgery is limited. This review provides a summary of multimodal prehabilitation studies in gynecologic oncologic surgery. Enhanced postoperative recovery, lower postoperative complications, lower rate of blood transfusions, and faster gastrointestinal functional recovery have been reported after multimodal prehabilitation interventions. Patients and healthcare professionals should recognize the importance of prehabilitation in the field of gynecologic oncologic treatment, based on the emerging evidence. In addition, there is a need to establish an appropriate target group and construct a well-designed and tailored prehabilitation program.

Understanding hospital length of stay in trauma laparotomy patients: a National Trauma Database Study

Introduction

The diverse procedures and varying patient conditions in trauma laparotomy cases lead to significant variability in hospital length of stay (HLOS), posing challenges for effective patient care. Strategies to reduce HLOS are varied, with multiple factors potentially modifiable through targeted interventions. These interventions are most effective when target populations and their associated factors are clearly defined. This study aimed to stratify trauma laparotomy patients by their HLOS and identify factors associated with HLOS to enhance patient care.

Methods

A retrospective analysis was conducted using the National Trauma Data Bank from January 2017 to December 2019. Adult trauma patients who underwent trauma laparotomy following blunt or penetrating abdominal injuries were identified using International Classification of Diseases, 10th Revision codes and Abbreviated Injury Scales. HLOS was stratified into three groups based on the IQR of the study population: short (< 5 days), medium (5-11 days) and long (> 11 days).

Results

A total of 27 434 trauma laparotomy patients were identified. The overall median HLOS was 7.0 (5.0, 11.0) days. Penetrating mechanisms, particularly stab wounds, were strongly associated with a short HLOS. Additionally, isolated abdominal trauma, splenic injuries or spleen-related procedure were more likely to result in a short HLOS. Patients with a long HLOS experienced higher rates of in-hospital complications and were more frequently discharged to home with home health services or to extended care facilities. Most comorbidities were associated with a long HLOS, and patients with Medicaid or Medicare had a higher likelihood of a long HLOS.

Conclusion

Despite the relatively homogenous trauma population, HLOS distribution varied significantly. Stratification based on HLOS revealed distinct factors associated with short and long HLOS categories, indicating that targeted interventions for each category could potentially reduce HLOS and enhance patient outcomes in the current era of constrained healthcare resources.

Level of evidence study type

Level IV, therapeutic/care management.

INDEPSO-ISPSM consensus on peritoneal malignancies - Enhanced recovery after surgery in cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC)

Background

The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context.

Method

The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2.

Results

After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.

Conclusion

Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.

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.

Analysis of protocol adherence and outcomes of an enhanced recovery program in colorectal surgery after 5 years of implementation

INTRODUCTION

Enhanced recovery program (ERAS program) have revolutionized the world of surgery by reducing postoperative complications and hospital stays. Greater adherence to the protocol results in better outcomes; however, adherence often declines over time. The main objective of this study is to analyze the adherence rate to ERAS strategies and the outcomes of an ERAS colorectal (CRC) program five years after its implementation.

METHODOLOGY

This is a descriptive observational study comparing two groups of patients undergoing scheduled CRC surgery under an ERAS program at University Hospital. The first group (ERAS) includes patients operated on during the period immediately following the implementation of the protocol (January 2017-June 2018), while the second group (ERAS 5) includes patients operated on five years after the implementation (January 2022-June 2022).

RESULTS

An increase in the adherence rate to ERAS strategies was observed (88.2% in ERAS vs. 84.2% in ERAS 5, p 0.003), as well as a reduction in healthcare-associated infections (HAIs) (9% in ERAS vs. 25.2% in ERAS 5, p 0.001) and surgical site infections (6% in ERAS vs. 18.2% in ERAS 5, p 0.002). No differences were found in other postoperative complications, functional recovery, average length of stay, and readmission rates.

CONCLUSIONS

After five years of implementing an ERAS protocol for CRC in our hospital, we have managed to maintain a high adherence rate to ERAS strategies. There has been a significant reduction in HAIs and surgical site infections.

Benefits of early recovery after surgery (ERAS) protocols on perioperative outcomes in patients undergoing elective lumbar spinal fusion: a prospective study

BACKGROUND CONTEXT

Enhanced Recovery After Surgery (ERAS) protocols have been shown to accelerate patient recovery across various surgical fields. There are growing reports of the benefits of ERAS for lumbar fusion, but the majority rely on retrospective analysis.

PURPOSE

This study aimed to prospectively assess the impact of an ERAS protocol on perioperative outcomes in patients undergoing lumbar spinal fusion.

STUDY DESIGN/SETTING

Prospective comparative cohort study conducted at a tertiary medical center in Taipei, Taiwan, between November 2020 and May 2023.

PATIENT SAMPLE

The study included 242 patients undergoing lumbar spinal fusion for degenerative spinal conditions divided into ERAS and non-ERAS groups.

OUTCOME MEASURES

Main outcomes measured included operative duration, estimated blood loss (EBL), postoperative nausea and vomiting (PONV), analgesic use, and visual analog scale (VAS) pain score.

METHODS

Propensity score matching (PSM) was used to minimize confounders between the 2 groups. Differences between the 2 groups were assessed using the 2-sample independent t-test or nonparametric Mann-Whitney U test for continuous variables, and the chi-square test or Fisher's exact test for categorical variables.

RESULTS

The ERAS group had significantly shorter operative time (202±68 min vs. 255±85 min) and EBL (480±302 ml vs. 641±387 ml) compared to the non-ERAS group. The ERAS group had significantly less total morphine-sulfate-equivalent (MSE) consumption (27±24 mg vs. 42±42 mg) and used patient-controlled analgesia (PCA) (97% vs. 41%) more frequently compared to the non-ERAS group. Notably, the ERAS group had a shorter time to ambulation and shorter time to removal of Foley catheters.

CONCLUSIONS

These data suggest that the employed ERAS protocol significantly enhances recovery trajectories and the need for analgesics in patients undergoing lumbar spinal fusion.

Artificial Intelligence in Cardiac Surgery: Transforming Outcomes and Shaping the Future

Background: Artificial intelligence (AI) has emerged as a transformative technology in healthcare, with its integration into cardiac surgery offering significant advancements in precision, efficiency, and patient outcomes. However, a comprehensive understanding of AI's applications, benefits, challenges, and future directions in cardiac surgery is needed to inform its safe and effective implementation. Methods: A systematic review was conducted following PRISMA guidelines. Literature searches were performed in PubMed, Scopus, Cochrane Library, Google Scholar, and Web of Science, covering publications from January 2000 to November 2024. Studies focusing on AI applications in cardiac surgery, including risk stratification, surgical planning, intraoperative guidance, and postoperative management, were included. Data extraction and quality assessment were conducted using standardized tools, and findings were synthesized narratively. Results: A total of 121 studies were included in this review. AI demonstrated superior predictive capabilities in risk stratification, with machine learning models outperforming traditional scoring systems in mortality and complication prediction. Robotic-assisted systems enhanced surgical precision and minimized trauma, while computer vision and augmented cognition improved intraoperative guidance. Postoperative AI applications showed potential in predicting complications, supporting patient monitoring, and reducing healthcare costs. However, challenges such as data quality, validation, ethical considerations, and integration into clinical workflows remain significant barriers to widespread adoption. Conclusions: AI has the potential to revolutionize cardiac surgery by enhancing decision making, surgical accuracy, and patient outcomes. Addressing limitations related to data quality, bias, validation, and regulatory frameworks is essential for its safe and effective implementation. Future research should focus on interdisciplinary collaboration, robust testing, and the development of ethical and transparent AI systems to ensure equitable and sustainable advancements in cardiac surgery.

Early non-compliance to ERAS in gynecological open surgery for malignancies, and post-operative complications: a multicenter, prospective, observational, cohort study

BACKGROUND

Open surgical procedures for gynecological malignancies have a potential risk of post-operative complications and hence prolonged hospitalization, despite adherence to an Enhanced Recovery After Surgery (ERAS) protocol.

PRIMARY OBJECTIVE

To investigate the relationship between non-compliance to an ERAS protocol in the post-operative setting and the rate of post-operative complications, in women who underwent open surgery for gynecological malignancies.

STUDY HYPOTHESIS

Early non-compliance with the ERAS protocol increases the risk of post-operative complications.

TRIAL DESIGN

Multicenter, prospective, observational, cohort study.

MAJOR INCLUSION CRITERIA

Patients with histologically proven gynecological cancer (endometrial, uterine, tubo-ovarian, and cervical) undergoing elective open surgery and managed according to ERAS guidelines.

EXCLUSION CRITERIA

Patients with post-operative recovery in an intensive care unit, undergoing anterior or total pelvic exenteration or intraperitoneal chemotherapy. Previous radiotherapy or previous non-gynecological major abdominal surgery.

PRIMARY ENDPOINT

Association of non-compliance with the ERAS protocol using five selected indicators on post-operative day 2 with the rate of 30-day post-operative complications.

SAMPLE SIZE

600 patients will be enrolled in the study.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

At present, 106 patients have been recruited. Based on this, the accrual should be completed in 2025. Results should be presented at the end of 2025.

TRIAL REGISTRATION

NCT05738902.

Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial

OBJECTIVE

Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT.

METHODS

A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded.

RESULTS

Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05).

CONCLUSION

Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.

Clinicians' views on implementing enhanced recovery after surgery: a descriptive qualitative study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have existed for the past three decades; these protocols may improve patient outcomes and healthcare costs. Yet, ERAS is difficult to implement, and there has been limited focus on processes used to promote ERAS use. Thus, the aim of this study was to identify and describe the barriers and enablers to implementing ERAS.

METHODS

In this qualitative descriptive sub-study, semi-structured interviews, guided by the Theoretical Domains Framework, were conducted with surgeons, anaesthetists, and nurses. Interviews were analyzed using inductive and deductive content analysis.

RESULTS

Three categories were found, which mapped to 12 domains in the Theoretical Domains Framework. Category 1 'realizing the value of ERAS, despite varying levels of exposure and motivation' showed clinicians' different views and knowledge towards ERAS, with a general belief that ERAS was evidence-based. Category 2, 'building momentum for ERAS implementation' outlined strategies to encourage clinicians to practice ERAS. The final category 'providing resources for ERAS' illustrated the tools and up-front costs needed for ERAS implementation.

CONCLUSION

Motivational strategies are required to inspire individual clinicians to adopt ERAS. Additionally, resources are needed for ERAS to guide practice and support implementation (i.e., staffing and time), underscoring the need for hospital leadership support.

Short- and long-term outcomes following perioperative ERAS management in patients undergoing minimally invasive radical gastrectomy after neoadjuvant chemotherapy: A single-center retrospective propensity score matching study

INTRODUCTION

Gastric cancer patients receiving neoadjuvant chemotherapy (NACT) are more vulnerable to perioperative stress. Enhanced recovery after surgery (ERAS) is widely used in surgical patients aiming at reducing stress responses. However, whether this approach is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT remained determined. So, the objective of this study is to investigate the effects of ERAS for this special group of gastric cancer patients.

MATERIAL AND METHODS

The data of gastric cancer patients who underwent minimally invasive radical gastrectomy after NACT were collected. Patients were divided into an ERAS group and a conventional group based on whether they received perioperative ERAS management. Propensity score matching was conducted to eliminate bias. Pre- and postoperative inflammatory and nutritional marker levels, postoperative complications, recovery indices and 3-year OS and RFS were observed.

RESULTS

A total of 252 patients were analyzed after 1:1 PSM, including 126 patients in the ERAS group and 126 in the conventional group. The results showed that the implementation of ERAS significantly reduced the levels of novel inflammatory indicators, improve nutritional status and accelerate postoperative recovery. We found that the 3-year OS (72.2 % vs. 66.7 %) and RFS (67.5 % vs. 61.9 %) in the ERAS group showed an improvement trend compared to those in the traditional group, especially for stage III patients, although these differences were not significant.

CONCLUSION

The perioperative ERAS program is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2024

This special article is the 17th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor in chief, Dr Kaplan, and the editorial board for the opportunity to continue this series, namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2024 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2024 begin with an update on perioperative rehabilitation and enhanced recovery in cardiothoracic surgery, with a focus on novel methods to best assess our patients in the preoperative period and the impact of implementing enhanced recovery care models on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into anemia, transfusions, and coronary artery bypass grafting outcomes with a focus on gender disparities. The third theme is focused on cardiothoracic transplantation, with discussions focusing on techniques related to lung transplantation, including mechanical circulatory support. The 4th theme is focused on mechanical circulatory support, with discussions exploring advancements in left ventricular assist devices highlight the evolving landscape of mechanical circulatory support and discussion of anticoagulation practices. The fifth and final theme is an update on medical cardiology, with a focus on the outcomes of transcatheter management of regurgitant pathology, device management in heart failure, and new techniques in catheter ablation. The themes selected for this article are only a few of the diverse advances in the specialty during 2024. These highlights will inform the reader of key updates on a variety of topics, leading to improvement in perioperative outcomes for patients with cardiothoracic and vascular disease.

Intrathecal Morphine and Ropivacaine for Quality of Recovery After Laparoscopic Colorectal Surgery: A Randomized Controlled Trial

Purpose

Intrathecal morphine is increasingly used for pain management in laparoscopic colorectal surgery. While ropivacaine shows advantages of reduced cardiotoxicity and faster motor recovery compared to bupivacaine, the impact of intrathecal morphine-ropivacaine combination on postoperative recovery quality remains unclear. This study aimed to evaluate this combination's effect on recovery outcomes after laparoscopic colorectal surgery.

Patients and Methods

In this randomized, double-blind, placebo-controlled trial, 78 patients undergoing laparoscopic colorectal surgery received either preservative-free intrathecal morphine 250 μg with ropivacaine 15 mg (Intrathecal group) or a sham subcutaneous saline injection (Control group). The primary outcome was the Quality of Recovery-15 (QoR-15) score 24 hours after surgery. Secondary outcomes included pain scores, opioid consumption, and adverse effects.

Results

The intrathecal group showed significantly higher QoR-15 scores 24 hours postoperatively compared to the control group (median [IQR]: 121 [109-128] vs 111 [102-116], p < 0.001), with improvements in pain management (p < 0.001), physical comfort (p = 0.001), and physical independence (p = 0.002). The intrathecal group had lower pain scores at rest (area under the curve 0-48 h: 66 [59-90] vs 107 [89-126], p < 0.001) and during coughing (152 [137-172] vs 191 [166-213], p < 0.001), particularly from 0.5 to 24 hours. They also required less postoperative morphine (0-48 h: 10 [6-20] vs 26 [22-36] mg, p < 0.001). While hypotension (43.6% vs 17.9%, p = 0.014) and pruritus (35.9% vs 2.6%, p < 0.001) were more frequent in the intrathecal group, but no respiratory depression occurred in either group.

Conclusion

Intrathecal morphine-ropivacaine administration improves 24-hour postoperative recovery quality and provides superior pain relief after laparoscopic colorectal surgery, despite increased but manageable side effects. Further research should focus on dose optimization and comparative studies of different intrathecal local anesthetic combinations.

Trial Registration

The Chinese Clinical Trial Registry, ChiCTR2100052337.

Enhanced recovery after surgery protocols for minimally invasive treatment of Achilles tendon rupture: Prospective single-center randomized study

BACKGROUND

Achilles tendon rupture is a common orthopedic injury, with an annual incidence of 11-37 per 100000 people, significantly impacting daily life. Minimally invasive surgery, increasingly favored for its reduced risks and comparable fixation strength to open surgery, addresses these challenges. Despite advantages like accelerated recovery, perioperative care poses emotional support, pain management, and rehabilitation challenges, impacting treatment efficacy and patient experience. To address these gaps, this study investigated the efficacy of a rapid rehabilitation protocol in enhancing recovery outcomes for minimally invasive Achilles tendon surgery, aiming to develop personalized, standardized care guidelines for broader implementation.

AIM

To evaluate a nursing-led rapid rehabilitation program for minimally invasive Achilles tendon repair surgery, providing evidence-based early recovery indicators.

METHODS

This study enrolled 160 patients undergoing channel-assisted minimally invasive Achilles tendon repair randomized into experimental and control groups. The experimental group received perioperative rapid rehabilitation nursing care, while the control group received standard care. The primary outcome measure was the Oswestry disability index score, with secondary outcomes including quality of life, Barthel index, patient satisfaction with nursing, incidence of complications, and rehabilitation adherence. Statistical analysis included appropriate methods to compare outcomes between groups. The study was conducted in a specific setting, utilizing a randomized controlled trial design.

RESULTS

All 160 patients completed the follow-up. The experimental group showed significantly greater improvements in key efficacy indicators: Postoperative Oswestry disability index score (8.688 vs 18.88, P < 0.0001), quality of life score (53.25 vs 38.99, P < 0.0001), and Barthel index (70.44 vs 51.63, P < 0.0001). The experimental group had a lower incidence of deep vein thrombosis (1.25% vs 10.00%, P = 0.0339) with a relative risk of 0.1250 (95% confidence interval: 0.02050-0.7421). Infection rates were lower in the experimental group (2.50% vs 11.25%, P = 0.0564). Hospital stay (5.40 days vs 7.26 days, P < 0.0001) and postoperative bed rest (3.34 days vs 5.42 days, P < 0.0001) were significantly shorter. Patient satisfaction was 100% in the experimental group vs 87.50% in the control group (P = 0.0031).

CONCLUSION

The rapid rehabilitation intervention significantly reduced pain, shortened hospital stays, and lowered complication rates, improving joint function and patient satisfaction.

Adequacy of oral intakes after cardiac surgery within an ERAS pathway: A prospective observational study

BACKGROUND

The 2019 Enhanced Recovery After Cardiac Surgery (ERACS) guidelines presented perioperative recommendations to optimize treatment for patients undergoing cardiac surgery (CS). However, the guidelines have not established postoperative nutrition recommendations. Limited studies have analyzed oral intakes after CS, but to our knowledge, none have done so in an ERACS pathway. The main objective of this study was to evaluate the adequacy of postoperative oral intakes, including adherence to oral nutrition supplements (ONSs).

METHODS

This was an observational prospective study. Postoperative oral intakes were analyzed from postoperative day (POD) 1 to 4, using direct observation of meal plates provided by the hospital. ONSs consumption was evaluated from POD2 to POD4. Adherence to other ERACS recommendations, including nutrition optimization before surgery, was recorded.

RESULTS

Forty-three patients were included in this study. Nutrition optimization before CS was offered to three (7%) patients. Forty-one (95%) patients resumed oral intakes on POD1. Mean oral calorie and protein intakes from POD2 to POD4 were 1088 ± 437 kcal and 0.8 ± 0.3 g/kg, respectively; however, 17 (41%) patients had calorie and protein intakes ≥70% of their estimated requirements. On POD2, ONSs consumption contributed 35% ± 19% and 38% ± 20% of calorie and protein intake, respectively. There was a significant decrease in ONSs consumption starting on POD3.

CONCLUSION

Within an ERACS pathway and with the contribution of ONSs, 41% of patients achieved sufficient oral intakes within the first 4 days after CS. The optimization of ONSs adherence on postoperative oral intakes should be further studied.

Evaluating perioperative risks in total knee arthroplasty patients with normal preoperative cardiac stress tests

INTRODUCTION

While it is generally accepted that most patients undergoing joint replacement do not require a cardiac stress test, individuals with existing or potential cardiac conditions may be at an increased risk of perioperative complications following primary total knee arthroplasty (TKA). This study aims to analyze the immediate postoperative outcomes of patients who underwent primary TKA, comparing those who had a cardiac stress test with no abnormal results and subsequent cardiac interventions to those who did not undergo a stress test.

MATERIALS AND METHODS

This retrospective cohort study utilized the TriNetX Research Network. The first cohort included patients who underwent a stress test within one year prior to their TKA, had no abnormal results, and did not undergo cardiac catheterization within two weeks post-stress test (Normal Stress Test). The second cohort consisted of patients who did not have a stress test in the year preceding their TKA (No Stress Test). The study analyzed data collected between January 1, 2003, and January 1, 2024. To control for confounding variables, propensity score matching was employed. P < 0.01 was considered significant.

RESULTS

A total of 13,881 patients successfully matched in each cohort. Within 30 days following TKA, patients in the Normal Stress Test cohort exhibited a significantly elevated risk of several complications: Transfusion (RR: 1.702), Myocardial Infarction (MI) (RR: 1.908), Acute Renal Failure (ARF) (RR: 1.504), Acute Posthemorrhagic Anemia (RR: 1.245), Wound Dehiscence (RR: 1.549), and Pneumonia (RR: 2.051). These results were consistent at the 90-day follow-up. Notably, the risk of death was only elevated before propensity score matching (RR: 2.115).

CONCLUSION

Our findings suggest that the underlying conditions prompting the use of a cardiac stress test, including congestive heart failure and renal insufficiency, may themselves be indicative of a higher overall perioperative risk, regardless of the stress test results.

LEVELS OF EVIDENCE

Level III: Case-control study or retrospective cohort study.

Comparison of the Efficacy of Indwelling Gastric Tubes in Preoperative and Postoperative Patients With Oral and Maxillofacial Malignancies

PURPOSE

To explore the optimal plan for the timing of indwelling gastric tube placement in oral and maxillofacial malignant tumor patients.

DESIGN

A prospective randomized controlled trial.

METHODS

80 patients with oral and maxillofacial tumor were selected, and 40 patients were Pre-operative group. The remaining 40 patients were the control group, called Postoperative group. The body weight and hospital stay of the two groups were observed before and after surgery. Blood samples were taken before surgery and 1, 3 and 7 days after surgery to detect hemoglobin and plasma albumin.

FINDINGS

The number of postoperative hospitalization days in the pre-operative group was significantly lower than that in the post-operative group; postoperative hemoglobin and plasma albumins were lower in both groups compared with the preoperative level.

CONCLUSIONS

Preoperative nasogastric tube ensured early postoperative administration of gastrointestinal nutrition, promoted postoperative plasma albumin recovery, and shortened the days of hospitalization.

The efficacy and safety of enhanced recovery after surgery (ERAS) Program in laparoscopic distal gastrectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although ERAS Program had some advantages in laparoscopic distal gastrectomy (LDG), its efficacy and safety remained unclear. We conducted a systematic review and meta-analysis to assess the efficacy and safety of the ERAS group and the traditional care (TC) group in LDG.

METHODS

Multiple databases were retrieved from 1 January 2000 to 30 April 2023. The risk ratio (RR), standardized mean difference (SMD) and their 95% confidence interval (CI) were used to estimate the results.

RESULTS

Our meta-analysis contained 17 randomized controlled trials (RCTs) studies, which comprised 1468 patients. Regarding efficacy, the ERAS group had significantly shorter postoperative time to first flatus (SMD = -1.29 [95% CI: -1.68, -0.90]), shorter time to first defecation (SMD = -1.26 [95% CI: -1.90, -0.61]), shorter hospital stays (SMD = -0.99 [95% CI: -1.34, -0.63]), and lower hospitalization costs (SMD = -1.17 [95% CI: -1.86, -0.48]) compared to the TC group. Furthermore, in the ERAS group, C-reactive protein levels were lower on postoperative days 1, 3 or 4, and 7; albumin levels were higher on postoperative days 3 or 4 and 7; and interleukin-6 levels were lower on postoperative days 1 and 3. Regarding safety, the overall postoperative complication rate was lower in the ERAS group (RR: 0.76 [95% CI: 0.60, 0.97]), but there was no significant difference in the individual postoperative complication rate. Other indicators were also not statistically significant.

CONCLUSION

The combination of ERAS Program with laparoscopy surgery was safe and effective for the perioperative management of patients with distal gastric cancer.

Mitigating and preventing perioperative opioid-related harm

PURPOSE OF REVIEW

Although necessary for treatment of acute pain, opioids are associated with significant harm in the perioperative period and further intervention is necessary perioperatively to mitigate opioid-related harm.

RECENT FINDINGS

Opioid-naive patients are often first exposed to opioids when undergoing surgery, which can result in significant harm. Despite their benefits in reducing acute postsurgical pain, they are also associated with risks ranging from mild (e.g., pruritis, constipation, nausea) to potentially catastrophic (e.g. opioid-induced ventilatory impairment, respiratory depression, death). Overprescribing of opioids can lead to opioid diversion and drug driving. In this review, we will discuss opioid-related harm and what strategies can be used perioperatively to mitigate this harm. Interventions such as optimizing nonopioid analgesia, implementing Enhanced Recovery after Surgery programs, effective respiratory monitoring, patient education and opioid stewardship programs will be discussed.

SUMMARY

We will review policy and guidelines regarding perioperative opioid management and identify challenges and future directions to mitigate opioid-related harm.

Safety of inpatient care in surgical settings: cohort study

OBJECTIVES

To estimate the frequency, severity, and preventability of adverse events associated with perioperative care, and to describe the setting and professions concerned.

DESIGN

Multicenter retrospective cohort study.

SETTING

11 US hospitals.

PARTICIPANTS

1009 patients from a randomly selected sample of 64 121 adults admitted for surgery during 2018.

MAIN OUTCOME MEASURES

Adverse events during inpatient perioperative care were assessed using a trigger method, identifying information previously associated with similar events, and from a comprehensive review of electronic health records. Trained nurses reviewed all records and flagged admissions with possible adverse events, which were then adjudicated by physicians, who confirmed the occurrence and characteristics of the events. Adverse events were classified as major if they resulted in serious harm requiring substantial intervention or prolonged recovery, involved a life threatening event, or led to a fatal outcome. Potentially preventable events included those definitively, probably, or possibly preventable.

RESULTS

Among 1009 patients reviewed, adverse events were identified in 38.0% (95% confidence interval 32.6 to 43.4), with major adverse events occurring in 15.9% (12.7 to 19.0). Of 593 identified adverse events, 353 (59.5%) were potentially preventable and 123 (20.7%) were definitely or probably preventable. The most common adverse events were related to surgical procedures (n=292, 49.3%), followed by adverse drug events (n=158, 26.6%), healthcare associated infections (n=74, 12.4%), patient care events (n=66, 11.2%), and blood transfusion reactions (n=3, 0.5%). Adverse events were most frequent in general care units (n=289, 48.8%), followed by operating rooms (n=155, 26.1%), intensive care units (n=77, 13.0%), recovery rooms (n=20, 3.3%), emergency departments (n=11, 1.8%), and other in-hospital locations (n=42, 7.0%). Professions most involved were attending physicians (n=531, 89.5%), followed by nurses (n=349, 58.9%), residents (n=294, 49.5%), advanced level practitioners (n=169, 28.5%), and fellows (n=68, 11.5%).

CONCLUSIONS

Adverse events were identified in more than one third of patients admitted to hospital for surgery, with nearly half of the events classified as major and most potentially preventable. These findings emphasize the critical need for ongoing improvement in patient safety, involving all health professionals, throughout perioperative care.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

An Evaluation Index System to Assess Nurse Competency in Enhanced Recovery After Surgery Programs: A Delphi Study

PURPOSE

To construct an index system to evaluate the competencies of nurses in enhanced recovery after surgery (ERAS) programs and provide a scientific foundation for their training and assessment.

METHODS

Utilizing a literature review and semi-structured interviews, a preliminary indicator system was constructed. Based on the preliminary indicator system, a Delphi questionnaire was developed and utilized to achieve consensus among experts in two rounds of Delphi studies. The indicators were selected based on a mean importance score greater than 4 and a coefficient of variation less than .25. The weights of the indicators were calculated using the Analytic Hierarchy Process.

RESULTS

The study developed a system that evaluates the competencies of nurses involved in ERAS programs, offering a reference for their training and evaluation. The final index system includes 7 primary indicators, 20 secondary indicators, and 66 tertiary indicators. The primary indicators consist of competencies in the following components: 1) Direct clinical practice (20 items); 2) Expert coaching and guidance (9 items); 3) Consultation (6 items); 4) Research (7 items); 5) Leadership (11 items); 6) Collaboration (8 items); and 7) Ethical decision-making (5 items).

CONCLUSION

The developed competency evaluation index system is reliable and can serve as a foundation for the selection, training, and assessment of ERAS nurses.

Perioperative Mortality: A Retrospective Cohort Study of 75,446 Noncardiac Surgery Patients

Objective

To evaluate whether major adverse cardiac events (MACE) continue to be a major causative factor for mortality after noncardiac surgery.

Patients and Methods

We performed retrospective study of 75,410 adult noncardiac surgery patients at Mayo Clinic Rochester, between January 1, 2016, and May 4, 2018. Electronic medical records were reviewed and data collected on all deaths within 30 days (n=692 patients) of surgery. The incidence of death due to MACE was calculated.

Results

Postoperative MACE occurred in 150 patients (21.4 events per 10,000 patients; 95% CI, 18.2-25.2 events per 10,000 patients) with most occurring within 3 days of surgery (n=113). Postoperative MACE events were associated with atrial fibrillation with rapid rate response in 25 patients (16.7%), sepsis in 15 patients (10%), and bleeding in 15 patients (10%). There were 12 intraoperative deaths of which 9 were due to exsanguination (75%) and the remaining 3 (25%) due to cardiac arrest. Of the 56 deaths on the first 24 hours after surgery, 7 were due to hemorrhage, 17 due to cardiovascular causes, 20 due to sepsis, and 7 due to neurologic disease. The leading cause of total death over 30 days postoperatively was sepsis (28%), followed by malignancy (27%), cardiovascular disease (12%) neurologic disease (12%), and hemorrhage (5%).

Conclusion

MACE was not the leading cause of death both intraoperatively and postoperatively.

Enhanced recovery after surgery (ERAS) guided gynecologic/oncology surgery - The patient's perspective

Objective

Enhanced recovery after surgery (ERAS) pathways have demonstrated improvements in outcomes following benign gynecologic and gynecologic oncology surgery. However, there is limited data reporting the benefit of ERAS from the patient's perspective. This study aimed to explore patient knowledge of and experience with ERAS-guided surgery.

Methods

This interpretive descriptive study included participants who had undergone ERAS-guided gynecologic and gynecologic oncology surgery in Alberta, Canada using convenience sampling. Semi-structured interviews explored patient knowledge of ERAS, overall experience with surgery and recommended changes for surgical care. An inductive thematic analysis was conducted.

Results

Eight females aged 26-76 years old participated in the study who had gynecologic (n = 4) and gynecologic oncology (n = 4) surgery. Six themes central to participant experience of ERAS-guided surgery were identified: patient expectations, individual motivation, values and support, healthcare provider communication, trust in healthcare providers, COVID-19 and care co-ordination. Overall, specific knowledge of ERAS was low. Expectations were set by previous experience of healthcare (previous surgery or occupation), as well as information provided by healthcare professionals. Participants whose expectations aligned with physical experience of ERAS provided favourable perspectives. Participants recommended improving the quality, relevance and availability of information and establishing accessible follow up strategies.

Conclusion

Based on the finding that knowledge about ERAS was minimal, we advocate for improved education pertaining to ERAS recommendations. Acknowledging patients' expertise and motivation to engage in their care maybe one strategy to improve compliance with ERAS guidelines and improve outcomes for both patients and the healthcare system.

Challenges in Enhanced Recovery After Surgery (ERAS) research

Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking 'Why is the patient still in hospital?' is the original premise for ERAS. Outcomes improve with increased compliance with recommended elements, but overcomplication of pathways can lead to cherry picking of elements that are convenient, resulting in 'partial ERAS'. As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) for benign ovarian cysts is safe and feasible in same-day discharge: a retrospective cohort study

BACKGROUND

Advances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes.

MATERIALS AND METHODS

The study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient's demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson's chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method's quick recovery nature.

RESULTS

Upon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185-0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158-0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071-679.859, P = 0.045).

CONCLUSION

In this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.

Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient's clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

Knowledge, attitude, and practice towards enhanced recovery after surgery among patients underwent thoracoscopy surgery

OBJECTIVE

Thoracoscopy has gained extensive utilization in managing pleural disorders, and enhanced recovery after surgery (ERAS) can improve patients' prognosis and expedite post-surgical recovery. This study aimed to investigate the knowledge, attitudes, and practices (KAP) towards ERAS among patients underwent thoracoscopy surgery.

METHODS

This cross-sectional study was conducted between September 2022 and August 2023, among patients underwent thoracoscopy surgery in 6 Secondary or Tertiary hospitals in the author's area. Demographic characteristics and KAP scores were collected by questionnaires, and clinical data were extracted from medical records.

RESULTS

A total of 309 valid questionnaires were collected, with 165 (53.40%) males and 202 (65.37%) aged ≤65 years old. The mean scores for KAP were 28.92±7.21 (possible range: 9-45), 53.60±6.73 (possible range: 13-65), and 43.45±5.50 (possible range: 10-50), respectively. SEM confirmed the positive associations between knowledge and attitude (β = 0.108, P = 0.019), knowledge and practice (β = 0.096, P = 0.004), and attitude and practice (β = 0.438, P<0.001). However, the KAP were found not associated with prognosis.

CONCLUSION

Patients underwent thoracoscopy surgery showed moderate knowledge, positive attitude, and appropriate practice towards ERAS. Preoperative education, personalized counseling, peer support groups, peer support groups, and follow-up care were recommended in further clinical practice.

The application of ERAS in the perioperative period management of patients for lung transplantation

Objective

To explore the application of enhanced recovery after surgery (ERAS) in the perioperative period of lung transplantation.

Methods

We retrospectively collected the clinical data of 27 lung transplant patients who underwent ERAS during the perioperative period, while 12 lung transplant patients receiving routine treatment served as controls. General information was collected, including the specific implementation plan of ERAS, the incidence of complications and survival rate during the perioperative period (<30 d), postoperative hospitalization indicators, the postoperative length of stay, and numerical rating scale (NRS) scores.

Results

Comparison of postoperative hospitalization indicators, the ERAS group compared with the control group, there were significant differences in postoperative ICU stay time (2.0(2.0,4.0) vs 4.5(3.0,6.0), p = 0.005), postoperative hospital stay time (18(15,26) vs 24(19.5,32.75), p = 0.016), duration of nasogastric tube (3(2,3) vs 4(2.25,4.75), p = 0.023), and first ambulation time (4(3,5) vs 5.8(4.5,7.5), p = 0.004). There was no significant difference in postoperative invasive mechanical ventilation time, time to eat after surgery, duration of urinary catheter and duration of chest tube between the ERAS group and the control group (p>0.05). The perioperative survival of the ERAS group was 81.5%, which was higher than the control group (66.7%), but there is no statistically significant difference. Comparison of post-extubation NRS scores, the ERAS group had lower NRS scores at 12 h (5.30 ± 0.14 vs 6.25 ± 0.75), 24 h (3.44 ± 0.64 vs 5.58 ± 0.9), 48 h (2.74 ± 0.66 vs 4.08 ± 0.79) and 72 h (1.11 ± 0.80 vs 2.33 ± 0.49) than the control group, the difference was statistically significant (p<0.01). Intra-group comparison, post-extubation 12 h comparison post-extubation 24 h, 48 h, 72 h, the NRS scores showed a gradual downward trend, the difference was statistically significant (p<0.01). In the comparison of perioperative complications, the ERAS group had a lower postoperative infection incidence than the control group, the difference was statistically significant (44.4% vs 83.3%, p = 0.037). The ERAS group had lower postoperative delirium incidence than the control group, the difference was statistically significant (11.1% vs 50%, p = 0.014). There was no significant difference in the incidence of acute rejection, primary graft loss (PGD), gastrointestinal (GI) complications and airway complications between two groups (p>0.05).

Conclusion

The ERAS can be applied to lung transplant patients to relieve postoperative pain, shorten postoperative tube time, and shorten postoperative stay. Perioperative pulmonary rehabilitation exercises are beneficial to reducing the occurrence of postoperative pulmonary complications.

Ready to Go Home? Nurses' Perspectives of Prolonged Admission for Patients Undergoing Video-Assisted Thoracic Surgery for Non-Small-Cell Lung Cancer in Denmark

Enhanced recovery after surgery programs with median postoperative hospitalization of 2 days improve outcomes after lung cancer surgery. This article explores nursing care practices for patients with lung cancer who remain hospitalized despite having recovered somatically. Qualitative focus group interviews were conducted with 16 nurses. Ricoeur's phenomenological hermeneutics underpins the methodology applied in this study, and we relied on Benner and Wrubel's theory. The nurses emphasized that the thoughts of patients with a recent lung cancer diagnosis revolve around more than the surgery. Nursing comprises not only practicalities but also attending to patients' stress and their coping with being struck with lung cancer and having undergone surgery. A counterculture emerged to counteract the logic of productivity, indicating that caring as a worthy end in itself may be underestimated in protocol-driven care. Prolonging hospitalization largely depends on clinical judgment. The nurses' aim is not to keep patients in the hospital but to avoid any needless suffering, allowing them to reclaim the primacy of caring.

Feasibility and usefulness of postoperative mobilization goals in the enhanced recovery after surgery (ERAS®) clinical pathway for elective colorectal surgery

PURPOSE

Despite mobilization is highly recommended in the ERAS® colorectal guideline, studies suggest that more than half of patients don't reach the daily goal of 360 min out of bed. However, data used to quantify mobilization are predominantly based on self-assessments, for which the accuracy is uncertain. This study aims to accurately measure postoperative mobilization in ERAS®-patients by validated motion data from body sensors.

METHODS

ERAS®-patients with elective bowel resections were eligible. Self-assessments and motion sensors (movisens: ECG-Move 4 and Move 4; Garmin: Vivosmart4) were used to record mobilization parameter from surgery to postoperative day 3 (POD3): Time out of bed, time on feet and step count.

RESULTS

97 patients were screened and 60 included for study participation. Self-assessment showed a median out of bed duration of 215 min/day (POD1: 135 min, POD2: 225 min, POD3: 225 min). The goal of 360 min was achieved by 16.67% at POD1, 21.28% at POD2 and 20.45% at POD3. Median time on feet objectively measured by Move 4 was 109 min/day. During self-assessment, patients significantly underestimated their "time on feet"-duration with 85 min/day (p = 0.008). Median number of steps was 933/day (Move 4).

CONCLUSION

This study confirmed with objectively supported data, that most patients don't reach the daily mobilization goal of 360 min despite being treated by an ERAS®-pathway with ERAS®-nurse. Even considering an empirically approximated underestimation, the ERAS®-target isn't achieved by more than 75% of patients. Therefore, we propose an adjustment of the general ERAS®-goals into more patient-centered, individualized and achievable goals.

REGISTRATION

This study is part of the MINT-ERAS-project and was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is "DRKS00027863".

Enhanced recovery after surgery in children with congenital scoliosis

To assess the impact of Enhanced Recovery After Surgery (ERAS) protocol in children undergoing corrective surgery for congenital scoliosis. A retrospective analysis was conducted on children undergoing surgical correction for congenital scoliosis, with participants categorized into either the ERAS group or the control group. Comparative evaluations were made across clinical, surgical, laboratory, and quality of life parameters. Following propensity score matching, 156 patients were analyzed. Within the initial 3 days following surgery, the ERAS cohort demonstrated lower pain intensity and exhibited higher daily oral intake compared to their counterparts in the control group. A mere 14.1% of patients in the ERAS group experienced a peak body temperature exceeding 38.5°, illustrating a significantly lower incidence compared to the 33.3% recorded in the control group. The ERAS cohort displayed expedited timeframes for the onset of initial bowel function and postoperative discharge when contrasted with the control group. Levels of IL-6 assessed on the third day post-surgery were markedly reduced in the ERAS group in comparison to the control group. Noteworthy is the similarity observed in postoperative hemoglobin and albumin levels measured on the first and third postoperative days between the two groups. Assessments of quality of life using SF-36 and SRS-22r questionnaires revealed comparable scores across all domains in the ERAS group when juxtaposed with the control cohort. ERAS protocol has demonstrated a capacity to bolster early perioperative recovery, alleviate postoperative stress responses, and uphold favorable quality of life outcomes in children undergoing corrective surgery for congenital scoliosis.

Safety and feasibility of enhanced recovery after surgery-based management model for ambulatory pediatric surgical procedures

BACKGROUND

There is still some room for optimizing ambulatory pediatric surgical procedures, and the preoperative and postoperative management quality for pediatric patients needs to be improved.

AIM

To discuss the safety and feasibility of the enhanced recovery after surgery (ERAS)-based management model for ambulatory pediatric surgical procedures.

METHODS

We selected 320 pediatric patients undergoing ambulatory surgery from June 2023 to January 2024 at The First People’s Hospital of Liangshan Yi Autonomous Prefecture. Of these, 220 received ERAS-based management (research group) and 100 received routine management (control group). General information, postoperative ambulation activities, surgical outcomes (operation time, postoperative gastrointestinal ventilation time, and hospital stay), postoperative pain visual analogue scale, postoperative complications (incision infection, abdominal distension, fever, nausea, and vomiting), and family satisfaction were compared.

RESULTS

The general information of the research group (sex, age, disease type, single parent, family history, etc.) was comparable to that of the control group (P > 0.05), but the rate of postoperative (2 h, 4 h, and 6 h after surgery) ambulation activities was statistically higher (P < 0.01), and operation time, postoperative gastrointestinal ventilation time, and hospital stay were markedly shorter (P < 0.05). The research group had lower visual analogue scale scores (P < 0.01) at 12 h and 24 h after surgery and a lower incidence of total postoperative complications than the control group (P = 0.001). The research group had higher family satisfaction than the control group (P = 0.007).

CONCLUSION

The ERAS-based management model was safe and feasible in ambulatory pediatric surgical procedures and worthy of clinical promotion.

A retrospective cohort study on enhanced recovery after surgery (ERAS) in patients with diabetic foot ulcer

Enhanced recovery after surgery (ERAS) has been successfully integrated into a diverse array of surgical fields to improve the quality and efficacy of treatment intervention. Nonetheless, the application of the ERAS protocol for patients with diabetic foot ulcer (DFU) subsequent to undergoing surgical procedures has not been previously explored. Therefore, this study aimed to investigate the effect of an enhanced recovery protocol on perioperative outcomes in patients with DFU following surgical procedures. A retrospective analysis was conducted on 112 patients with DFU who underwent surgery between January 2020 and December 2021 at a tertiary referral care center. In total, 57 patients received standard perioperative care (the non-ERAS group), and 55 patients received ERAS care (the ERAS group). The primary outcomes included the length of stay (LOS), wound healing time, patient satisfaction, and costs, serving as the basis for assessing the effectiveness of the two approaches. Secondary outcomes included preoperative anxiety (APAIS score), nutritional status (PG-SGA), pain (NRS score), the incidence of lower-extremity deep vein thrombosis (DVT), the reduction in lower-limb circumference, and the activity of daily living scale (Barthel Index). The ERAS group exhibited significantly shorter LOS (11.36 vs. 26.74 days; P < 0.001) and lower hospital costs (CNY 62,165.27 vs. CNY 118,326.84; P < 0.001), as well as a higher patient satisfaction score and Barthel Index score (P < 0.05). Additionally, we found a lower APAIS score, incidence of DVT, and circumference reduction in lower limbs in the ERAS group compared to the non-ERAS group (P < 0.05). In comparison, the wound healing time, nutritional status, and pain levels of participants in both groups showed no significant difference (P > 0.05). By reducing the LOS and hospital costs, and by minimizing perioperative complications, the ERAS protocol improves the quality and efficacy of treatment intervention in patients with DFU who underwent surgical procedures.Trial registration number: ChiCTR 2200064223 (Registration Date: 30/09/2022).

Predictive model for prolonged hospital stay risk after gastric cancer surgery

Background

Prolonged postoperative hospital stay following gastric cancer (GC) surgery is an important risk factor affecting patients' mood and increasing complications. We aimed to develop a nomogram to predict risk factors associated with prolonged postoperative length of stay (PLOS) in patients undergoing gastric cancer resection.

Methods

Data were collected from 404 patients. The least absolute shrinkage and selection operator (LASSO) was used for variable screening, and a nomogram was designed. The nomogram performance was evaluated by the area under the receiver operating characteristic curve (AUC). The consistency between the predicted and actual values was evaluated via a calibration map, and the clinical application value was evaluated via decision curve analysis (DCA) and clinical impact curve analysis (CICA).

Results

A total of 404 patients were included in this study. Among these patients, 287 were assigned to the training cohort, and 117 were assigned to the validation cohort. According to the PLOS quartile distance, 103 patients were defined as having prolonged PLOS. LASSO regression and logistic multivariate analysis revealed that 4 clinical characteristics, the neutrophil-lymphocyte ratio (NLR) on postoperative day one, the NLR on postoperative day three, the preoperative prognostic nutrition index and the first time anal exhaust was performed, were associated with the PLOS and were included in the construction of the nomogram. The AUC of the nomogram prediction model was 0.990 for the training set and 0.983 for the validation set. The calibration curve indicated good correlation between the predicted results and the actual results. The Hosmer-Lemeshow test revealed that the P values for the training and validation sets were 0.444 and 0.607, respectively, indicating that the model had good goodness of fit. The decision curve analysis and clinical impact curve of this model showed good clinical practicability for both cohorts.

Conclusion

We explored the risk factors for prolonged PLOS in GC patients via the enhanced recovery after surgery (ERAS) program and developed a predictive model. The designed nomogram is expected to be an accurate and personalized tool for predicting the risk and prognosis of PLOS in GC patients via ERAS measures.

Racial and ethnic differences in early death among gynecologic malignancy

BACKGROUND

Racial and ethnic differences in early death after cancer diagnosis have not been well studied in gynecologic malignancy.

OBJECTIVE

This study aimed to assess population-level trends and characteristics of early death among patients with gynecologic malignancy based on race and ethnicity in the United States.

STUDY DESIGN

The National Cancer Institute's Surveillance, Epidemiology, and End Results Program was queried to examine 461,300 patients with gynecologic malignancies from 2000 to 2020, including uterine (n=242,709), tubo-ovarian (n=119,989), cervical (n=68,768), vulvar (n=22,991), and vaginal (n=6843) cancers. Early death, defined as a mortality event within 2 months of the index cancer diagnosis, was evaluated per race and ethnicity.

RESULTS

At the cohort level, early death occurred in 21,569 patients (4.7%), including 10.5%, 5.5%, 2.9%, 2.5%, and 2.4% for tubo-ovarian, vaginal, cervical, uterine, and vulvar cancers, respectively (P<.001). In a race- and ethnicity-specific analysis, non-Hispanic Black patients with tubo-ovarian cancer had the highest early death rate (14.5%). Early death racial and ethnic differences were the largest in tubo-ovarian cancer (6.4% for Asian vs 14.5% for non-Hispanic Black), followed by uterine (1.6% for Asian vs 4.9% for non-Hispanic Black) and cervical (1.8% for Hispanic vs 3.8% to non-Hispanic Black) cancers (all, P<.001). In tubo-ovarian cancer, the early death rate decreased over time by 33% in non-Hispanic Black patients from 17.4% to 11.8% (adjusted odds ratio, 0.67; 95% confidence interval, 0.53-0.85) and 23% in non-Hispanic White patients from 12.3% to 9.5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.71-0.85), respectively. The early death between-group difference diminished only modestly (12.3% vs 17.4% for 2000-2002 [adjusted odds ratio for non-Hispanic White vs non-Hispanic Black, 0.54; 95% confidence interval, 0.45-0.65] and 9.5% vs 11.8% for 2018-2020 [adjusted odds ratio, 0.65; 95% confidence interval, 0.54-0.78]).

CONCLUSION

Overall, approximately 5% of patients with gynecologic malignancy died within the first 2 months from cancer diagnosis, and the early death rate exceeded 10% in non-Hispanic Black individuals with tubo-ovarian cancer. Although improving early death rates is encouraging, the difference among racial and ethnic groups remains significant, calling for further evaluation.

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: a prospective cohort study

BACKGROUND

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains.

MATERIALS AND METHODS

An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery.

RESULTS

A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery.

CONCLUSION

Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis

Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.

Bispectral Index Monitoring Effect on Delirium Occurrence and Nursing Quality Improvement in Post-anesthesia Care Unit Patients Recovering From General Anesthesia: A Randomized Controlled Trial

BACKGROUND

The effect of intraoperative anesthesia depth monitoring on delirium occurrence and improvement of nursing quality in the post-anesthesia care unit (PACU) remains unclear. We aimed to explore the effect of intraoperative anesthesia bispectral index (BIS) monitoring on delirium occurrence and improvement of nursing quality in the PACU for patients recovering from general anesthesia.

METHODS

 This randomized controlled trial included 120 patients, aged 20-80 years, classified as grades I-III according to the American Society of Anesthesiologists. The BIS-guided group (group B) underwent intraoperative monitoring of BIS anesthesia depth (maintained within the anesthetic range (40-60)). The depth of anesthesia was not monitored in the non-BIS-guided group (group C). The patient's vital signs were recorded at the beginning of the operation (T0), upon entering the PACU (T1), 15 min after extubation (T2), and after leaving the PACU (T3). Delirium score, emergence period (extubation and PACU observation times), and adverse events in the PACU were monitored. The nursing activity score (NAS) was used to evaluate the quality of care.

RESULTS

Group B exhibited significantly lower heart rate and mean arterial pressure at T1 and T2, shorter time to extubation and PACU observation time, and a significantly lower incidence of adverse events than group C. Group B had significantly lower Ricker sedation-agitation scores and a lower incidence of delirium than group C. The NAS was significantly lower for group B than for group C. Patients aged 60-80 years in group C experienced agitation, requiring 30% more frequent assistance from one or two nurses than those in group B.

CONCLUSION

Intraoperative BIS monitoring can reduce the incidence of adverse events in the PACU, diminish the incidence of delirium during the recovery period in elderly patients, lessen the nursing workload, improve nursing quality, and promote patient rehabilitation, thus meriting clinical application.

Low-pressure versus standard-pressure pneumoperitoneum in minimally invasive colorectal surgery: a systematic review, meta-analysis, and meta-regression analysis

Background

We aimed to assess the efficacy and safety of low-pressure pneumoperitoneum (LPP) in minimally invasive colorectal surgery.

Methods

A PRISMA-compliant systematic review/meta-analysis was conducted, searching PubMed, Scopus, Google Scholar, and clinicaltrials.gov for randomized-controlled trials assessing outcomes of LPP vs standard-pressure pneumoperitoneum (SPP) in colorectal surgery. Efficacy outcomes [pain score in post-anesthesia care unit (PACU), pain score postoperative day 1 (POD1), operative time, and hospital stay] and safety outcomes (blood loss and postoperative complications) were analyzed. Risk of bias2 tool assessed bias risk. The certainty of evidence was graded using GRADE.

Results

Four studies included 537 patients (male 59.8%). LPP was undertaken in 280 (52.1%) patients and associated with lower pain scores in PACU [weighted mean difference: -1.06, 95% confidence interval (CI): -1.65 to -0.47, P = 0.004, I 2  = 0%] and POD1 (weighted mean difference: -0.49, 95% CI: -0.91 to -0.07, P = 0.024, I 2  = 0%). Meta-regression showed that age [standard error (SE): 0.036, P < 0.001], male sex (SE: 0.006, P < 0.001), and operative time (SE: 0.002, P = 0.027) were significantly associated with increased complications with LPP. In addition, 5.9%-14.5% of surgeons using LLP requested pressure increases to equal the SPP group. The grade of evidence was high for pain score in PACU and on POD1 postoperative complications and major complications, and blood loss, moderate for operative time, low for intraoperative complications, and very low for length of stay.

Conclusions

LPP was associated with lower pain scores in PACU and on POD1 with similar operative times, length of stay, and safety profile compared with SPP in colorectal surgery. Although LPP was not associated with increased complications, older patients, males, patients undergoing laparoscopic surgery, and those with longer operative times may be at risk of increased complications.

Multimodal prehabilitation and postoperative outcomes in upper abdominal surgery: systematic review and meta-analysis

The impact of multimodal prehabilitation on postoperative complications in upper abdominal surgeries is understudied. This review analyzes randomized trials on multimodal prehabilitation with patient and hospital outcomes. MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched for trials on prehabilitation before elective (non-emergency) abdominal surgery. Two reviewers independently screened studies, extracted data, and assessed study quality. Primary outcomes of interest were postoperative pulmonary complications (PPCs) and all-cause complications; secondary outcomes included hospital and intensive care length of stay. A meta-analysis with random-effect models was performed, and heterogeneity was evaluated with I-square and Cochran's Q test. Dichotomous variables were reported in log-odds ratio and continuous variables were presented as mean difference. Ten studies (total 1503 patients) were included. Odds of developing complications after prehabilitation were significantly lower compared to various control groups (- 0.38 [- 0.75- - 0.004], P = 0.048). Five studies described PPCs, and participants with prehabilitation had decreased odds of PPC (- 0.96 [- 1.38- - 0.54], P < 0.001). Prehabilitation did not significantly reduce length of stay, unless exercise was implemented; with exercise, hospital stay decreased significantly (- 0.91 [- 1.67- - 0.14], P = 0.02). Multimodal prehabilitation may decrease complications in upper abdominal surgery, but not necessarily length of stay; research should address heterogeneity in the literature.