Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications

Role of ileal diversion in pediatric inflammatory bowel disease

Surgical intervention is often indicated in pediatric inflammatory bowel disease (IBD) for medically refractory disease or complications of severe disease. Specifically, surgical intervention via ileal diversion allows for fecal flow to be redirected away from diseased distal bowel and through an ileostomy. It is utilized in patients who have medically refractory colitis, severe perianal disease, or irreversible bowel damage. In patients with ulcerative colitis, it is primarily performed during a restorative proctocolectomy with ileal pouch anal anastomosis to protect the high-risk anastomoses. In the setting of Crohn's disease, ileal diversion reduces the exposure of diseased distal intestine to pro-inflammatory stool. During perioperative planning, it is crucial for the gastroenterologist to partner early with a multidisciplinary team including surgeons, nutritionists, wound ostomy care nurses, psychologists, and social workers. Patients should be assessed for malnutrition and should be optimized nutritionally with enteral or parenteral nutrition. As they are associated with increased risk of postoperative complications, corticosteroids should be significantly reduced or completely discontinued preoperatively. Though ileal diversion may reduce the complications associated with anastomosis, serious postoperative complications can include diversion colitis and high-output fistulae. This review aims to provide an overview of the role of ileal diversion in the treatment of pediatric IBD to pediatric gastroenterologists to inform their medical decision-making and discussions with patients and families.

The effects of oral nutritional supplements interventions on nutritional status in patients undergoing colorectal cancer surgery: A systematic review

BACKGROUND

The high incidence of malnutrition in patients undergoing colorectal cancer surgery can lead to unplanned weight loss, sarcopenia and reduced grip strength to the extent that it can seriously affect the prognosis of colorectal cancer patients.

OBJECTIVE

This study investigated the effect of oral nutritional supplements (ONS) on the prevalence of grip strength, unplanned weight loss and sarcopenia in patients undergoing colorectal cancer surgery.

METHODS

We systematically searched randomized controlled studies from CINAHL, PubMed, Embase, Cochrane and Web of Science and three Chinese databases (CNKI, Wan-Fang database, VIP database) from database creation to September 2023. The risk of bias in individual studies was assessed using the Cochrane Collaboration tool, and the certainty of evidence was assessed using the five GRADE criteria. Statistical analysis was performed using the RevMan 5.3 software, and information that could not be meta-analysed was reviewed in the form of a literature summary.

RESULTS

Eleven papers met the inclusion criteria with a combined sample size of 1070 cases, including 532 cases in the trial group and 538 cases in the control group. Four papers reported the effect of ONS on grip strength and included very low-quality evidence supporting no effect of ONS on grip strength. Ten studies reported the effect of ONS on body weight and body mass index (BMI) and included very low-quality evidence supporting a positive ONS on weight and BMI changes. Meta-analysis showed a significant reduction in weight loss (12-15 weeks) and BMI loss (12-15 weeks) in patients with colorectal cancer in the ONS group. The effect of ONS on the prevalence of sarcopenia after hospital discharge was reported in two studies, and meta-analysis showed a significant reduction in the prevalence of postoperative sarcopenia in colorectal cancer patients in the ONS group, but the quality of evidence was low.

CONCLUSIONS

This study showed that the use of ONS in patients undergoing surgery for colorectal cancer improved patient weight loss and BMI reduction and reduced the prevalence of postoperative sarcopenia but did not improve patient grip strength. The quality of evidence for inclusion in the article was low or very low, and further studies are needed to provide better evidence.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

[Enteral nutrition in postoperative rehabilitation after reconstructive esophageal and gastric surgery]

OBJECTIVE

To investigate enteral nutrition as a component of postoperative rehabilitation after reconstructive esophageal and gastric surgeries.

MATERIAL AND METHODS

The study included 217 patients who underwent reconstructive esophageal and gastric surgeries between 2010 and 2020. In the main group (n=121), patients underwent postoperative enhanced recovery program (ERAS). Early enteral feeding including micro-jejunostomy and early oral feeding was essential for postoperative management. The control group included 96 patients who were treated in traditional fashion. The primary endpoint was length of hospital-stay (LOS) and ICU-stay. Restoration of gastrointestinal function (peristalsis, stool, oral nutrition), anastomotic leakage rate and other complications comprised secondary endpoints.

RESULTS

Both groups did not differ by sex, age, body mass index, diagnosis and comorbidities. There was significant reduction in postoperative LOS in the ERAS group (14 (12; 15.8) and 9 (6.3; 12) days, p<0.0001). In the same group, we observed less in ICU-stay (4.7 (3.6; 5.6) and to 3.5 (2; 4) days, p<0.001), earlier recovery of peristalsis and X-ray control of anastomosis in patients with and without anastomotic leakage. Incidence of respiratory complications was lower in the ERAS group (p=0.034). Overall postoperative morbidity and mortality were similar.

CONCLUSION

Early enteral and oral feeding after esophageal and gastric reconstructive surgery reduces hospital-stay and accelerates postoperative rehabilitation.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes.

METHODS

An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients.

RESULTS

There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol.

CONCLUSIONS

ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality

INTRODUCTION

To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe.

METHODS

All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD.

RESULTS

There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC.

CONCLUSION

Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed.

Effects of Postdischarge High-Protein Oral Nutritional Supplements and Resistance Training in Malnourished Surgical Patients: A Pilot Randomized Controlled Trial

The presence of malnutrition is increasingly becoming a postdischarge problem in surgical patients. We aimed to investigate whether oral nutritional supplements combined with resistance training could minimize skeletal muscle atrophy in surgical patients after discharge. This randomized controlled study was conducted at the Department of Surgery, National Hospital of Faroe Islands from 2018 to 2020. A total of 45 patients aged 37−74 years participated and were allocated to one of three groups: diet (DI; n = 13), exercise and diet (EX + DI; n = 16), or control (CON; n = 16). The intervention period lasted 8 weeks. The intervention groups received individual dietary counselling and a protein-rich oral nutritional supplement twice a day containing 22 g of protein/day. Patients in the EX + DI group were assigned to resistance training sessions. Patients in the CON group received standard care. The primary outcome was change in lean body mass (LBM). Secondary outcomes were change in body weight, handgrip strength, quality of life, surgery-related side effects, energy and protein intake, length of stay and one-year mortality. To estimate within-group changes, linear mixed models including group−time interactions as fixed effects and patients as random effects were fitted. Within-group change in LBM was 233, 813 and 78 g in the DI, EX + DI and CON groups, respectively, with no significant between-group difference (p > 0.05). Pain score declined more (p = 0.04) in the EX + DI group compared with the CON group. Body weight, handgrip strength, quality of life and surgery-related side effects did not differ between groups. At the end of study, mean cumulative weight change in the DI and EX + DI groups was 0.4% and 1.6%, respectively, whereas the CON group experienced a weight loss of −0.6%. No significant difference in primary outcome between groups was noted. However, our results indicate some benefits from exercise and nutrition for malnourished surgical patients.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs.

OBJECTIVE

To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program.

METHODS

69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis.

RESULTS

Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition.

CONCLUSION

Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey

BACKGROUND

Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines.

METHODS

An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake.

RESULTS

Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001).

CONCLUSIONS

The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs.

OBJECTIVE

To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program.

METHODS

69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis.

RESULTS

Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition.

CONCLUSION

Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Factors associated with diet failure after colon cancer surgery

BACKGROUND

Since the introduction of Enhanced Recovery After Surgery (ERAS), early diet after surgery has been emphasized and clinical outcomes have improved, though vomiting has been reported frequently. We defined diet failure based on clinical manifestation and images after colon cancer surgery and attempted to analyze underlying risk factors by comparing the early diet group with the conventional diet group.

METHODS

All consecutive patients underwent colectomy with curative intent at a single institution between August 2015 and July 2017. The early diet group was started on soft diet on the second day after surgery, while the conventional group started the same after flatulence. The primary outcome was the difference in the incidence of diet failure between the two groups. Secondary outcomes were analyzed to determine risk factors for diet failure and readmission due to ileus.

RESULTS

Overall, 293 patients were included in the conventional diet group and 231 in the early diet group. There were no significant differences between the two groups, except for shorter hospital stays in the early diet group (median 8 days, p < 0.001). A total of 46 patients (early diet, n = 20; conventional diet, n = 26, p = 1.000) had diet failure. Multivariate analysis showed that operation time (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.33-2.32) and side-to-side anastomosis compared with the end-to-end method (OR 4.41, 95% CI 2.10-9.24) were independent risk factors for diet failure. Sixteen patients were readmitted due to ileus that occurred within 2 months after surgical operation. Diet resumption time was not a risk factor for both diet failure and ileus.

CONCLUSIONS

Early diet resumption does not increase diet failure and can reduce hospital stay. Anastomosis and operation time may be related to diet failure. Our study suggests that evaluation of surgical factors is important for postoperative recovery, and well-designed follow-up studies are needed.

Assessment of an integrated knowledge translation intervention to improve nutrition intakes among patients undergoing elective bowel surgery: a mixed-method process evaluation

BACKGROUND

A large evidence-practice gap exists regarding provision of nutrition to patients following surgery. The aim of this study was to evaluate the processes supporting the implementation of an intervention designed to improve the timing and adequacy of nutrition following bowel surgery.

METHODS

A mixed-method pilot study, using an integrated knowledge translation (iKT) approach, was undertaken at a tertiary teaching hospital in Australia. A tailored, multifaceted intervention including ten strategies targeted at staff or patients were co-developed with knowledge users at the hospital and implemented in practice. Process evaluation outcomes included reach, intervention delivery and staffs' responses to the intervention. Quantitative data, including patient demographics and surgical characteristics, intervention reach, and intervention delivery were collected via chart review and direct observation. Qualitative data (responses to the intervention) were sequentially collected from staff during one-on-one, semi-structured interviews. Quantitative data were summarized using median (IQR), mean (SD) or frequency(%), while qualitative data were analysed using content analysis.

RESULTS

The intervention reached 34 patients. Eighty-four percent of nursing staff received an awareness and education session, while 0% of medical staff received a formal orientation or awareness and education session, despite the original intention to deliver these sessions. Several strategies targeted at patients had high fidelity, including delivery of nutrition education (92%); and prescription of oral nutrition supplements (100%) and free fluids immediately post-surgery (79%). Prescription of a high energy high protein diet on postoperative day one (0%) and oral nutrition supplements on postoperative day zero (62%); and delivery of preoperative nutrition handout (74%) and meal ordering education (50%) were not as well implemented. Interview data indicated that staff regard nutrition-related messages as important, however, their acceptance, awareness and perceptions of the intervention were mixed.

CONCLUSIONS

Approximately half the patient-related strategies were implemented well, which is likely attributed to the medical and nursing staff involved in intervention design championing these strategies. However, some strategies had low delivery, which was likely due to the varied awareness and acceptance of the intervention among staff on the ward. These findings suggest the importance of having buy-in from all staff when using an iKT approach to design and implement interventions.

Nasogastric- vs. percutaneous gastrostomy tube for prophylactic gastric decompression after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with postoperative gastroparesis and ileus. In 2015, our practice shifted from using percutaneous gastrostomy tubes (PGT), to nasogastric tubes (NGT) for prophylactic gastric decompression after CRS-HIPEC. This study aimed to compare these methods for length of stay (LOS) and associated complications.

Methods

Patients that underwent CRS-HIPEC for peritoneal metastases from colorectal cancer between 2014 and 2019 were included. Cases were grouped based on receiving NGT or PGT postoperatively. Multivariable linear regression determined the independent effect of decompression method on LOS, thereby adjusting for confounders.

Results

In total, 179 patients were included in the analyses. Median age was 64 years [IQR:54–71]. Altogether, 135 (75.4%) received a NGT and 44 (24.6%) received a PGT. Gastroparesis occurred significantly more often in the PGT group (18.2 vs. 7.4%, p=0.039). Median LOS was significantly shorter for patients with a NGT (15 [IQR:12–19] vs. 18.5 [IQR:17–25.5], p<0.001). PGT was independently associated with longer LOS in multivariable analysis (Beta=4.224 [95%CI 1.243–7.204]). There was no difference regarding aspiration, pneumonia and postoperative mortality between groups.

Conclusions

NGT should be preferred over PGT for gastric decompression after CRS-HIPEC as it is associated with fewer gastroparesis and shorter LOS.

Enhanced Recovery after Robot-Assisted Partial Nephrectomy for Cancer: Is it Better for Patients to Have a Quick Discharge?

OBJECTIVES

The aim of the study was to assess the efficacy and safety of an enhanced recovery program (ERP) after robot-assisted partial nephrectomy (RAPN) for cancer.

METHODS

It was a monocentric, retrospective, comparative study. An ERP after RAPN was introduced at our institution in 2015 and proposed to all consecutive patients admitted for RAPN. The control group for this study was composed of patients managed immediately before the introduction of the ERP. We collected information on patient characteristics, tumor sizes, ischemia times, biology, hospital length of stays, postoperative (≤30 days) complications, and readmission rates. Group comparisons were made using the Pearson χ2 test for qualitative data and the Student t test for quantitative data.

RESULTS

Between 2015 and 2017, 112 patients were included in the ERP group. Fifty patients were included in the control group. Ninety patients in the ERP group (80.4%) were discharged at or before postoperative day (POD) 2 versus 10 patients (20%) in the control group (p < 0.001). There was no significant difference between the ERP and control groups for the urinary retention rate (respectively 3.6 vs. 2%; p = 0.593). Resumption of normal bowel function was significantly shorter in the ERP group (94.6% at POD1 vs. 69.6% in the control group, p < 0.001). There were no significant differences for postoperative complications (15.2% in the ERP group vs. 20% in the control group, p = 0.447) or readmissions within 30 days (8.04 vs. 0.2%, p = 0.140).

CONCLUSIONS

ERP after RAPN seems to reduce postoperative length of stay without increasing postoperative complications or readmissions.

Equine nutrition in the post-operative colic: Survey of Diplomates of the American Colleges of Veterinary Internal Medicine and Veterinary Surgeons, and European Colleges of Equine Internal Medicine and Veterinary Surgeons

Background

Evidence is lacking concerning re‐introduction of feed and water following colic surgery.

Objectives

To describe current approaches of European and American specialists to re‐introduction of feed and water in adult horses following surgical treatment of common intestinal lesions, assuming an uncomplicated recovery.

Study design

Cross‐sectional survey.

Methods

Electronic invitations, with a link to the online survey, were sent to 1,430 large animal specialists, including Diplomates of the ECVS, ACVS, ECEIM and ACVIM colleges.

Results

The response rate was 12.6% including partial respondent data. Responses for each multiple‐choice question were between 123 and 178. Results are expressed as the percentage of the total number of responses and as a range where specific lesions are grouped together. Respondents reported that horses with large intestinal displacements were offered free choice water (63%‐65%) within 3 hours (55%‐63%), whereas horses with a small intestinal strangulating lesion were offered < 2 L water (64%‐74%) 12‐24 hours (28%‐34%) post‐operatively. Horses with a large colon displacement were offered feed within 3 hours of surgery (16%) with the majority offered feed 6‐12 hours (35%‐36%) post‐operatively. Horses with small intestinal strangulating lesions and small colon lesions were offered feed 24‐48 hours (34%‐42%) after surgery. Following small intestinal, small colon or caecal lesions, horses were re‐introduced feed in handfuls (79%‐93%) and initially with grass (41%‐54%). Horses with large colon displacements were mostly fed handfuls (49%‐50%) of forage initially, but a number of respondents would offer larger quantities such as a small bucket (35%‐37%) and predominantly of hay (50%‐51%).

Main limitations

Low response rate. This study did not take into account common post‐operative complications that may alter the clinical approach.

Conclusions

This post‐operative colic nutrition survey is the first to describe current clinical practice. Further research is required to investigate nutritional strategies in post‐operative colic cases.

Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols

Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization.

METHODS

A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization.

RESULTS

Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively).

CONCLUSION

Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

BACKGROUND

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

METHODS

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

RESULTS

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

CONCLUSION

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Early Feeding after Colorectal Surgery in Children: Is it Safe?

Aim of the Study

The aim of this study is to assess the role of early feeding after elective colorectal surgery in children and compare the outcome of feeding practice early versus traditional feeding.

Study Design

A randomized controlled, single-center study was conducted over a period of 3 years (November 2015-October 2018) at a tertiary care center.

Materials and Methods

Patients (n = 147), after colostomy closure (as elective colorectal surgery), were randomly selected for postoperative feeding initiation and were divided into two groups, namely the control (traditional feeding) group and study group (early feeding). In early group, feeding was initiated on the postoperative day 1 after the removal of nasogastric tube (removed after 16 h of surgery). Postoperative hospital stay and complications were compared among them.

Statistical Analysis Used

Data were tabulated and analyzed in Microsoft Excel 2010.

Results

Among 147 patients (boys[70] and girls [77]), the average age of colostomy closure was 4.36 years. Forty-five patients had early feeding and 102 traditional feeding. Average postoperative hospital stay was noted 5.62 ± 1.11 days for "Study group" and 8.1 ± 1.04 days for "Control group." Postoperative complications were found in 17 patients; 11 (7.5%) superficial surgical site infection (9 [8.8%] in control and 2 [4.4%] in study group) and 6 (4%) minor fecal fistulae (5 [4.9%] in control group and 1 [2.2%] in study group). None required any further surgical intervention. No mortality was reported.

Conclusions

Early feeding initiation after elective colorectal surgery is safe, and postoperative hospital stay is significantly reduced. It is definitely a step forward in the era of fast track surgery in pediatric population.

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices.

OBJECTIVE

The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes.

METHODS

A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria.

RESULTS

Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes.

CONCLUSIONS

ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure.

CLINICAL RELEVANCE

This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Less Opioid Consumption With Enhanced Recovery After Surgery Transforaminal Lumbar Interbody Fusion (TLIF): A Comparison to Standard Minimally-Invasive TLIF

Objective

The concept of enhanced recovery after surgery (ERAS) is relatively new to the neurosurgical field. The introduction of an ERAS protocol in lumbar fusion surgery has aimed to accelerate patient recovery from surgery by reducing in-hospital opioid consumption.

Methods

Patients with 1- or 2-level degenerative lumbar spine disease and who underwent ERAS transforaminal lumbar interbody fusion (TLIF) were retrospectively reviewed. Patients’ general demographic data, in-hospital opioid dosage (converted to morphine equivalents), and hospital stay were compared to those who underwent standard minimally-invasive (MIS)-TLIF.

Results

Twenty-four patients who received ERAS TLIF (the ERAS group) were compared to a series of 24 patients who received standard MIS-TLIF (the MIS group). The demographic data were similar. The operation time and blood loss significantly favored ERAS TLIF. The average daily opioid consumption was remarkably lower in the ERAS group than the MIS group. Average opioid dosage throughout the entire in-hospital period was also significantly reduced in the ERAS group compared to the MIS group. The average length of hospital stay was substantially shorter in the ERAS group (1.4 ± 1.13 days vs. 4.0±1.98 days, p <0.001).

Conclusion

The present study demonstrated a significant decline in the consumption of opioids and in the hospital length of stay for patients undergoing ERAS TLIF for 1- or 2-level degenerative lumbar spine disease.

Clinical Outcomes of Percutaneous Endoscopic Gastrostomy in the Surgical Intensive Care Unit

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) is usually performed on patients with chronic underlying diseases in the general ward (GW). This study evaluated the clinical outcomes of PEG performed on patients in the surgical intensive care unit (SICU) compared with those of PEG performed in the GW.

Methods

The medical records of 27 patients in the SICU and 263 in the GW, who underwent PEG between January 2013 and July 2017, were retrospectively reviewed.

Results

The median age of the 27 SICU patients was 66 years, and their median body mass index was 21.1 kg/m². In the SICU group, the median baseline Sequential Organ Failure Assessment (SOFA) score was 4, and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 16. The median interval between surgery and PEG in SICU patients was 30 days, with a PEG failure rate of 3.7%. Acute complications in SICU patients included bleeding (7.4%) and ileus (11.1%), while chronic complications included aspiration pneumonia (7.4%) and tube obstruction (3.7%). The rates of acute and chronic complications did not differ significantly between the SICU and GW groups. The 30-day mortality rate was 14.8% in SICU patients and 5.3% in GW patients (p=0.073).

Conclusions

PEG is a safe and feasible method of enteral feeding for critically ill patients who require ICU care after surgery.

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Introduction

Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.

Aim

To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.

Methods

Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.

Results

Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.

Conclusions

There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift

Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.

The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery-a systematic review and meta-analysis of randomised controlled trials

BACKGROUND/OBJECTIVES

Despite best practice guidelines, feeding methods after colorectal surgery vary due to the difficulties translating evidence into practice. The aim was to determine the effectiveness of diets delivered into the gastrointestinal tract (GIT) on gut motility following colorectal surgery.

SUBJECTS/METHODS

EMBASE, MEDLINE, CINAHL, Web of Science and PubMed were systematically searched. Randomised controlled trials investigating effectiveness of a diet on gut motility after colorectal surgeries were included. Outcomes included postoperative ileus, length of stay, mortality, nausea and vomiting.

RESULTS

A total of 756 potential studies were identified; of these, 10 trials reporting on 1237 unique patients were included. There is evidence that early feeding reduces time (days) to first flatus (mean difference (MD):-0.64; 95% CI:-0.84 to -0.44) and bowel movements (MD:-0.64; 95% CI:-1.01 to -0.26), when compared to traditional postoperative fasting. Introducing solids versus the progression of fluids to solids had no effect on time (days) to first flatus (MD:0.13; 95% CI:-1.99 to 1.74) or bowel movement (MD:0.20; 95% CI:-0.50 to 0.98). Complete nutrition compared to hypocaloric nutrition had no effect on time to first flatus (MD:-0.60; 95% CI:-1.66 to 0.46) or bowel movement (MD:-0.20; 95% CI:-1.59 to 1.19), whereas coffee and diet compared to water and diet significantly decreased time (days) to first bowel movement (MD:-0.60; 95% CI:-0.97 to -0.19) but had no effect on time to first flatus (MD:-0.20; 95% CI:-0.57 to 0.09).

CONCLUSIONS

Any form of early postoperative diet provided into the GIT early after colorectal surgery is likely to stimulate gut motility, resulting in earlier return of bowel function and shorter length of stay.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Diet and inflammatory bowel disease: The Asian Working Group guidelines

INTRODUCTION

These Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries.

METHODOLOGY

The guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

Diet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature

Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.

Enhanced Recovery for Breast Reconstruction Surgery

PURPOSE OF REVIEW

Enhanced recovery pathways are a well-described perioperative healthcare program involving evidence-based interventions. Enhanced recovery is designed to standardize techniques such as drug selection and nerve blocks in order to speed recovery and reduce overall hospital costs.

RECENT FINDINGS

A PubMed literature search was performed for articles that included the terms enhanced recovery and breast reconstruction surgery. The present investigation summarizes enhanced recovery literature related to breast surgery with a focus on breast reconstruction. Enhanced recovery considerations discussed in this review include patient education, preadmission optimization, perforator flap planning, anesthetic techniques, optimized fasting, venous thrombosis prophylaxis, early mobilization, and antimicrobial prophylaxis.

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

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Implementation of Enhanced Recovery after Surgery (ERAS) Program in Perioperative Management of Gastric Cancer Surgery: a Nationwide Survey in Korea

Purpose

Despite its clinical benefits, enhanced recovery after surgery (ERAS) is less widely implemented for gastric cancer surgery. This nationwide survey investigated the current status of the implementation of ERAS in perioperative care for gastric cancer surgery in South Korea.

Materials and Methods

This survey enrolled 89 gastric surgeons from 52 institutions in South Korea. The questionnaire consisted of 24 questions about the implementation of the ERAS protocols in the management of gastric cancer surgery. The survey was carried out using an electronic form sent via email.

Results

Of the 89 gastric surgeons, 58 (65.2%) answered that they have knowledge of the concept and details of ERAS, 45 (50.6%) of whom were currently applying ERAS for their patients. Of the ERAS protocols, preoperative education (91.0%), avoidance of preoperative fasting (68.5%), maintenance of intraoperative normothermia (79.8%), thromboprophylaxis (96.5%), early active ambulation (64.4%), and early removal of urinary catheter (68.5%) were relatively well adopted in perioperative care. However, other practices, such as avoidance of preoperative bowel preparation (41.6%), provision of preoperative carbohydrate-rich drink (10.1%), avoidance of routine abdominal drainage (31.4%), epidural anesthesia (15.9%), single-dose prophylactic antibiotics (19.3%), postoperative high oxygen therapy (36.8%), early postoperative diet (14.6%), restricted intravenous fluid administration (53.9%), and application of discharge criteria (57.3%) were not very well adopted for patients.

Conclusions

Perioperative management of gastric cancer surgery is largely heterogeneous among gastric surgeons in South Korea. Standard perioperative care based on scientific evidence needs to be established to improve the quality of surgical care and patient outcomes.

An observational study of perioperative nutrition and postoperative outcomes in patients undergoing laparotomy at Queen Elizabeth Central Hospital in Blantyre, Malawi

Background

Nutritional status in patients undergoing surgery can influence their immune function, tissue repair and, hence, clinical outcomes. This study aimed to assess the perioperative nutrition and postoperative outcome of patients undergoing laparotomy at a tertiary hospital in Malawi.

Methods

A total of 25 patients were included in this prospective, observational study. The Subjective Global Assessment was used to classify each patient according to nutritional status. Handgrip strength was measured for each patient preoperatively and at day 3 postoperatively. Anthropometric measurements were also done. Protein and energy requirements for each participant were estimated and compared to the quantities provided by the hospital diet. Patients were followed up until discharge and outcome variables which included length of hospital stay and wound dehiscence or infectious complications were recorded.

Results

Of the study participants, 20% were well-nourished, 52% were moderately malnourished and 28% were severely malnourished. The median handgrip strength decreased at day 3 postoperatively from the preoperative handgrip strength. Well-nourished patients had higher handgrip strength than malnourished patients both preoperatively and postoperatively. Total energy and protein provided by the hospital diet were significantly lower than the estimated requirements for the patients. Severely malnourished patients had increased median length of hospital stay and increased rate of postoperative complications. Preoperative and postoperative day 3 handgrip strength correlated negatively with the number of postoperative complications and length of hospital stay.

Conclusion

This study showed high rates of malnutrition and inadequate in-hospital nutritional support which were associated with poor clinical outcomes, especially in severely malnourished patients. Proper nutritional assessment and provision of adequate nutritional support should be reinforced in surgical patients to promote favourable clinical outcomes postoperatively. Further studies with larger sample sizes in other patient populations and hospitals in Malawi are required in this area.

Ordering a Normal Diet at the End of Surgery-Justified or Overhasty?

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011–2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04–1.32), fluid overload (OR 1.38; 95% CI 1.16–1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27–1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38–0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36–0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Enhanced recovery after surgery decreases intestinal recovery time and pain intensity in patients undergoing curative gastrectomy

Background

Enhanced recovery after surgery (ERAS) reduces postoperative stress, increases patient satisfaction, and reduces postoperative stay and cost. In this study, we evaluated the feasibility and effectiveness of ERAS protocols compared with conventional perioperative care group and their effect in gastric cancer patients undergoing gastrectomy.

Methods

A cohort of 366 patients were analyzed from a prospectively maintained database. The patients’ characteristics, tumor profile, surgical information data and postoperative complications were evaluated.

Results

Patients in the ERAS had a faster gastrointestinal function recovery and first flatus (3.26±0.64; P<0.001). Pain intensity of patients in the ERAS group was significantly lower than that of patients in the conventional care group on postoperative days 1 (2.33±0.98; P<0.001) and 3 (1.06±0.63; P<0.001). Postoperative hospital stays were significantly shorter in patients receiving ERAS program (6.66±3.36; P<0.001), than in those patients who received conventional perioperative care (9.02±2.61).

Conclusion

ERAS can reduce postoperative stress, enhance the recovery of the gut, reduce the pain intensity, and increase satisfaction in gastric cancer patient undergoing curative gastrectomy.

Pharmaconutrition administration on outcomes of elective oncological surgery for gastrointestinal malignancies: is timing everything?-a review of published meta-analyses until the end of 2016

The last 25 years have seen an increasing number of publications attesting the benefits of pharmaconutrition in the management of patients undergoing elective oncological gastrointestinal surgery. A number of randomized controlled trials and meta-analyses suggest the use of pharmaconutrition in this group of patients produces superior outcomes to standard nutritional formulations in terms of postoperative infective complications, anastomotic breakdown and length of hospital stay. The use of pharmaconutrition products, therefore, has gained increasing acceptance for use in elective gastrointestinal oncological surgical populations and been incorporated into practice guidelines. However, there remains doubts as to the robustness of such data supporting these recommendation. This is because studies reporting improved outcomes with pharmaconutrition (I) frequently compare this intervention with non-equivalent control groups; (II) do not report on the actual nutritional provision received by study participants; (III) overlook the potential impact of industry funding on research conducted and (IV) do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, a critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is urgently warranted to resolve some of the above mentioned issues. The aim of this review was to analyse meta-analyses published until the end of 2016 in this area to highlight the strengths and weakness of the present research and prioritize certain areas which will benefit from future research.

Anesthetic drugs modulate feeding behavior and hypothalamic expression of the POMC polypeptide precursor and the NPY neuropeptide

Background

Several hypnotic drugs have been previously identified as modulators of food intake, but exact mechanisms remain unknown. Feeding behavior implicates several neuronal populations in the hypothalamic arcuate nucleus including orexigenic neuropeptide Y and anorexigenic pro-opiomelanocortin producing neurons. The aim of this study was to investigate in mice the impact of different hypnotic drugs on food consumption and neuropeptide Y or pro-opiomelanocortine mRNA expression level in the hypothalamic arcuate nucleus.

Methods

Saline control, isoflurane, thiopental, midazolam or propofol were administered to C57Bl/6 mice. Feeding behavior was evaluated during 6 h. In situ hybridization of neuropeptide Y and pro-opiomelanocortine mRNAs in the hypothalamus brain region was also performed. Data were analyzed by Kruskal Wallis test and analysis of variance (p < 0.05).

Results

Midazolam, thiopental and propofol induced feeding behavior. Midazolam and thiopental increased neuropeptide Y mRNA level (respectively by 106 and 125%, p < 0.001) compared with control. Propofol and midazolam decreased pro-opiomelanocortine mRNA level by 31% (p < 0,01) compared with control. Isoflurane increased pro-opiomelanocortine mRNA level by 40% compared with control.

Conclusion

In our murine model, most hypnotics induced food consumption. The hypnotic-induced regulation of neuropeptide Y and pro-opiomelanocortine hypothalamic peptides is associated with this finding. Our data suggest that administration of some hypnotic drugs may affect hypothalamic peptide precursor and neuropeptide expression and concomittantly modulate food intake. Thus, this questions the choice of anesthetics for better care management of patients undergoing major surgery or at risk of undernutrition.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0557-x) contains supplementary material, which is available to authorized users.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients&rsquo; mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery

The purpose of the review

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery.

Recent findings

ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function.

Summary

Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Early Versus Delayed (Traditional) Postoperative Oral Feeding in Patients Undergoing Colorectal Anastomosis

BACKGROUND

A period of starvation after colorectal anastomosis to permit for resolution of the clinical evidence of ileus has been an unchallenged surgical dogma until recent years. We intended to determine the safety and feasibility of an unconventional postoperative oral intake protocol in patients experiencing colorectal anastomosis.

MATERIALS AND METHODS

Between 2013 and 2015, sixty consecutive patients underwent colorectal anastomosis and they were randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way - nothing by mouth until the complete resolution of ileus.

RESULTS

The majority of patients (93%) tolerated the early feeding. The times to first passage of flatus (2.66 ± 0.71 days vs. 3.9 ± 0.071 days) and stool (3.9 ± 0.92 days vs. 5.4 ± 0.77 days) were significantly quicker in early feeding group. Hospital stay was also significantly shorter in the early feeding group (4 ± 0.64 days vs. 6.1 ± 0.84 days). Anastomosis leakage and abscess formation were not seen in early feeding group. The patient's satisfaction (visual analog scale) in the early feeding group was higher than delayed feeding group (8.56 ± 1.16 vs. 7.06 ± 1.59, P < 0.001).

CONCLUSIONS

Early oral feeding after colorectal surgeries is safe and tolerated by the majority of patients.

Normal Diet within Two Postoperative Days-Realistic or Too Ambitious?

Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46–0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12–2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10–2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08–2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32–5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I–V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb–V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake.

Best practice in major elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS)

Within traditional clinical care, the postoperative recovery after pelvic/rectal surgery has been slow with high morbidity and long hospital stay. The enhanced recovery after surgery program is a multimodal approach to perioperative care designed to accelerate recovery and safely reduce hospital stay. This review will briefly summarize optimal perioperative care, before, during and after surgery in this group of patients and issues related to implementation and audit.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre

BACKGROUND

Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted.

METHODS

A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups.

RESULTS

The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up.

CONCLUSIONS

Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Chewing Gum for Intestinal Function Recovery after Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis

Background

This meta-analysis was performed to assess the efficacy and safety of chewing gum in intestinal function recovery after colorectal cancer surgery.

Methods

A systematic search was conducted in PubMed, Embase, Science Direct, and Cochrane library for relevant randomized controlled trials (RCTs) published until April 2017. Summary risk ratios or weighted mean differences with 95% confidence intervals were used for continuous and dichotomous outcomes, respectively.

Results

17 RCTs with a total number of 1845 patients were included. Gum chewing following colorectal cancer surgery significantly reduced the time to first passage of flatus (WMD −0.55; 95% CI −0.94 to −0.16; P = 0.006), first bowel movement (WMD −0.60; 95% CI −0.87 to −0.33; P < 0.0001), start feeding (WMD −1.32; 95% CI −2.18 to −0.46; P = 0.003), and the length of postoperative hospital stay (WMD −0.88; 95% CI −1.59 to −0.17; P = 0.01), but no obvious differences were found in postoperative nausea, vomiting, abdominal distention, pneumonia, and mortality, which were consistent with the findings of intention to treat analysis.

Conclusions

Chewing gum could accelerate the recovery of intestinal function after colorectal cancer surgery. However, it confers no advantage in postoperative clinical complications. Further large-scale and high-quality RCTs should be conducted to confirm these results.