A protocol is not enough to implement an enhanced recovery programme for colorectal resection

Association of self-efficacy, risk attitudes, and time preferences with health-related quality of life and functioning after total hip or knee replacement - Results of the MobilE-TRA 2 cohort

BACKGROUND

While total hip and knee replacement (THR/TKR) surgery are effective measures to restore functioning and reduce pain in patients with severe osteoarthritis (OA), long-term treatment effects vary among patients. Following behavioral economic theory, these differences may be partially attributed to the impact of personality traits on individual strategies to approach post-surgical challenges. This study explored the associations between self-efficacy, willingness to take risk regarding health (H-WTTR), and future orientation, and the 3-month course of health-related quality of life (HRQoL) and OA-specific health status.

METHODS

As part of the prospective and observational MobilE-TRA 2 cohort study, 147 patients aged 60 years and older were assessed by self-administered questionnaires before and three months after THR/TKR at a single German hospital. As indicators for the surgical outcome, HRQoL was assessed by the EuroQol Five-Dimensional Five-Level Questionnaire (EQ-5D-5L), including the visual analogue scale (EQ-VAS), and functioning was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) using the global score, function score, and pain score. All WOMAC scores were transformed into scales with 0 = worst health and 100 = best health. Self-efficacy was measured using the General Self-Efficacy Short Scale. H-WTTR and future orientation were assessed by single-item questions on 11-point Likert scales. The associations between these personality traits and the 3-month change in the outcome scores were analyzed using linear regression models for THR and TKR respectively.

RESULTS

In THR patients a one-point-increase in self-efficacy was associated with improvements in EQ-5D-5L (β=0.0704; p=0.0099), WOMAC global (β=6.6337; p=0.0139), WOMAC function (β=8.2557; p=0.0046), and WOMAC pain (β=5.9994; p=0.0232). For TKR, only the association of self-efficacy with the EQ-VAS change-score was significant (β=5.8252; p=0.0482). Self-efficacy demonstrated weak positive, but not significant associations with all WOMAC scores and a negative association close to zero with the EQ-Index. H-WTTR and future orientation showed no significant associations to changes of the outcome scores.

CONCLUSIONS

Self-efficacy appears to be a prognostic factor for better THR/TKR outcomes after three months. If these findings can be confirmed in further research, strategies to improve self-efficacy should be considered in prehabilitation programs.

TRIAL REGISTRATION

Not applicable.

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

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

A bibliometric analysis of perioperative rehabilitation research between 2005 and 2024

Effective rehabilitation can improve the prognosis of surgical patients, thereby enhancing their medical experience. In recent years, relatively more research is been carried out in this field; therefore, it is necessary to use bibliometric analysis to understand the development status and main research hotspots of perioperative rehabilitation, so as to determine the role of rehabilitation in the perioperative period. All documents related to perioperative rehabilitation and published from 2005 to 2024 were retrieved from the Web of Science Core Collection (Woscc). Number of articles, countries/regions, institutions, journals, authors, and keywords were analysed using VOSviewer and CiteSpace. A total of 829 studies on perioperative rehabilitation were included in the bibliometric analysis. The number of articles has steadily and rapidly increased since 2016. Over time, the publication outputs increased annually. There are 532 keyword nodes in total, of which the five keywords that appear most frequently are "surgery" "rehabilitation" "Outcome" "management" and "complications". Research on the perioperative rehabilitation has developed rapidly. This study provides necessary information for researchers to understand the current status, collaborative networks, and main research hotspots in this field. In addition, our research findings provide a series of recommendations for future studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhanced recovery protocol for congenital duodenal obstruction - initial experiences with development and implementation

BACKGROUND

The experience with Enhanced Recovery After Surgery® (ERAS®) protocols in neonatal intestinal surgery is very limited. We present the development and implementation of an Enhanced Recovery Protocol (ERP) designed specifically for neonates treated for congenital duodenal obstruction (CDO), and early outcome after implementation.

METHODS

An ERP for CDO was developed and implemented. Experiences with ERP development and implementation are described. Early clinical outcome in patients treated before (January 2015-Descember 2020) and after (February 2022-September 2024) implementation were compared. Ethical approval was obtained.

RESULTS

A multidisciplinary ERP team was established. The ERP for CDO was developed with stakeholder involvement. Implementation was challenging, but with close follow-up and frequent meetings with the involved medical disciplines, an overall ERP compliance of 80% was achieved for the 21 patients treated after implementation. Compared to 40 patients treated before ERP implementation (January 2015-Descember 2020), the use of minimally invasive surgery increased and time to first postoperative enteral and breast feed were reduced, without increasing the rate of postoperative complications.

CONCLUSIONS

This study presents an ERP specifically designed for CDO with a unique description of our experiences with the development and implementation process. Early results suggest that this ERP for CDO is feasible and safe.

Clinical impact of an enhanced recovery protocol implementation for nephrectomy and radical prostatectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is a combination of multimodal pathways to improve surgical outcomes. Recommendations for radical cystectomy have been published by the ERAS society for the cystectomy but a lack of evidence is observed for urological procedures such as nephrectomy (Ne) and radical prostatectomy (RP). The aim of our study was to evaluate the impact of enhanced recovery protocol implementation for Ne ad RP at our academic institution.

METHODS

We performed a retrospective, monocentric, comparative analysis, pre and post implementation of an enhanced recovery protocol for patients undergoing robotic-assisted radical prostatectomy or nephrectomy (partial or total) for cancer. The primary endpoint was the mean length of stay (LOS). Secondary endpoints included 30-days readmission, postoperative complications, 90 days survival, and oncologic outcome at 6 months.

RESULTS

We included 264 patients between January, 2019, and December, 2020. Statistical analysis was performed separately by type of surgery. The LOS of patients included in the ERP protocol was decreased on average by 1.3 days IC95% [-2.50; -0.08], P<0.001 for nephrectomies and by 2.2 days IC95% [-3.72; -0.62] P<0.001 for prostatectomies, compared to non-ERP patients. There were no more re-admission, death or oncologic recurrence.

CONCLUSION

In our experience, ERP for oncological nephrectomy and prostatectomy reduced the length of stay, without increasing postoperative complications and readmission.

LEVEL OF EVIDENCE

IV.

Enhanced recovery after surgery (ERAS) in advanced therapeutic flexible endoscopy: Introducing the concept of enhanced recovery after therapeutic endoscopy (ERATE)

Enhanced recovery after surgery (ERAS) guidelines are evidence-based recommendations designed to improve patient outcomes and reduce complications after surgery. Although the ERAS guidelines focus primarily on surgical procedures, many of the principles could be applied also to therapeutic endoscopy as well. An extensive literature research on Embase and PubMed was thus made to reviewed articles regarding ERAS protocols applied to therapeutic endoscopy, organized by specific endoscopic field. Out of 214 papers, only 6 were relevant to the topic. Few studies explored in real life and in trial setting the hypothesized significance of ERAS principles applied to endoscopic procedures, mostly retrospective, not even covering the entire field of therapeutic endoscopy. This field of knowledge appears neglected so far by scientific community and endoscopic organizations. We believe that endoscopy units could benefit anyway from developing and implementing structured enhanced recovery pathways for their patients, therefore we subsequently created and suggested a simply and easily applicable, Enhanced Recovery protocol After Therapeutic Endoscopy which include preoperative preparation, anesthesia and sedation, nausea and vomiting (PONV) prophylaxis, and postoperative care.

The EUropean PErioperative MEdical Networking (EUPEMEN) project and recommendations for perioperative care in colorectal surgery: a quality improvement study

BACKGROUND

Despite consensus supporting enhanced recovery programs, their full implementation in such a context is difficult due to conventional practices within various groups of professionals. The goal of the EUropean PErioperative MEdical Networking (EUPEMEN) project was to bring together the expertise and experience of national clinical professionals who have previously helped deliver major change programs in their countries and to use them to spread enhanced recovery after surgery protocols (ERAS) in Europe. The specific aim of this study is to present and discuss the key points of the proposed recommendations for colorectal surgery.

MATERIALS AND METHODS

Five partners from university hospitals in four European countries developed the project as partners. Following a non-systematic review of the literature, the European consensus panel generated a list of recommendations for perioperative care in colorectal surgery. A list of recommendations was formulated and distributed to collaborators at each center to allow modifications or additional statements. These recommendations were then discussed in three consecutive meetings to share uniform ERAS protocols to be disseminated.

RESULT

The working group developed (1) the EUPEMEN online platform to offer, free of charge, evidence-based standardized perioperative care protocols, learning activities, and assistance to health professionals interested in enhancing the recovery of their patients; (2) the preparation of the EUPEMEN Multimodal Rehabilitation manuals; (3) the training of the trainers to teach future teachers; and (4) the dissemination of the results in five multiplier events, one for each partner, to promote and disseminate the protocols.

CONCLUSION

The EUPEMEN project allowed the sharing of the expertise of many professionals from four different European countries with the objective of training the new generations in the dissemination of ERAS protocols in daily clinical practice through a new learning system. This project was proposed as an additional training tool for all the enhanced recovery program teams.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

Motivational Interviewing improves postoperative nutrition goals within the Enhanced Recovery after Surgery (ERAS®) pathway in elective bowel surgery - A randomized clinical pilot trial

BACKGROUND & AIMS

Exploration whether Motivational Interviewing (MI) could be learned and implemented with ease within a surgical in-hospital setting and whether participation in the intervention led to significantly higher compliance with ERAS®-recommended protein intake goals. The individual healing process of many patients is delayed because they fail to cover their calorie requirement, which could be counteracted by a patient-centered conversational intervention that is new in perioperative practice.

METHODS

This patient-blinded pilot-RCT included 60 patients (≥18 years) following the certified ERAS® bowel protocol for colorectal surgery between March and August 2022. Five perioperative MI interventions were conducted by two health employees certified to perform MI. Key endpoints were the number of protein shakes drunk, calories of proteins ingested and overall calorie intake.

RESULTS

A total of 60 patients (34 men [56.7%]; mean [SD] age, 60.7 [13.3] years) were randomized. MI patient-group had significantly higher protein shake intake on all postoperative days except day 3. For days 0-3 MI group drank significantly more shakes overall (median 5.5 vs. 2.0; P = 0.004) and consumed more calories (median 1650.0 vs. 600.0 kcal; P = 0.004) and proteins (median 110.0 vs. 40.0 g; P = 0.005). Total calorie intake for each day by shakes and dietary intake was significantly higher in the MI-intervention group on day 2 (mean 1772.3 vs. 1358.9 kcal; P = 0.03).

CONCLUSIONS

MI may contribute to improve compliance with nutritional goals in the certified ERAS® protocol by increasing protein and calorie intake. The findings suggest further investigation of MI to help patients achieve their perioperative nutrition goals in different clinical settings.

TRIAL REGISTRATION

DRKS - Deutsches Register Klinischer Studien; DRKS-ID: DRKS00027863; https://drks.de/search/de/trial/DRKS00027863.

Evolving concepts on perioperative nutrition of sarcopenic cancer patients

The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.

Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals

OBJECTIVE

The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success.

BACKGROUND

Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success.

METHODS

We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time.

RESULTS

Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives.

CONCLUSION

We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Evolution of enhanced recovery for children undergoing elective intestinal surgery

Enhanced recovery protocols (ERP) have been widely adopted in adult populations, with over 30 years of experience demonstrating the effectiveness of these protocols in patients undergoing gastrointestinal (GI) surgery. In the last decade, ERPs have been applied to pediatric populations across multiple subspecialties. The objective of this manuscript is to explore the evolution of how ERPs have been implemented and adapted specifically for pediatric populations undergoing GI surgery, predominantly for inflammatory bowel disease. The reported findings reflect a thorough exploration of the literature, including initial surveys of practice/readiness assessments, consensus recommendations of expert panels, and data from a rapidly growing number of single center studies. These efforts have culminated in a national prospective, multicenter trial evaluating clinical and implementation outcomes for enhanced recovery in children undergoing GI surgery. In short, this historical and clinical review reflects on the evolution of ERPs in pediatric surgery and expounds upon the next steps needed to apply ERPs to future pediatric populations.

Sustainability of enhanced recovery after surgery programmes in gastrointestinal surgery: A scoping review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention that is well-recognised across multiple surgical specialties as having potential to lead to improved patient and hospital outcomes. Little is known about sustainability of ERAS programmes.

AIMS

This review aimed to describe available evidence evaluating sustainability of ERAS programmes in gastrointestinal surgery to understand: (a) how sustainability has been defined; (b) examine determinants of sustainability; (c) identify strategies used to facilitate sustainability; (d) identify adaptations to support sustainability; and (e) examine outcomes measured as indicators of sustainability of ERAS programmes.

METHODS

This scoping review was conducted following the Joanna Briggs Institute's methodology. Research databases (PubMed, Embase, CINHAL) and the grey literature were searched (inception to September 2022) for studies reporting sustainability of ERAS programmes in gastrointestinal surgery. Included articles reported an aspect of sustainability (i.e., definition, determinants, strategies, adaptations, outcomes and ongoing use) at ≥2 years following initial implementation. Aspects of sustainability were categorised according to relevant frameworks to facilitate synthesis.

RESULTS

The search strategy yielded 1852 records; first round screening excluded 1749, leaving 103 articles for full text review. Overall, 22 studies were included in this review. Sustainability was poorly conceptualised and inconsistently reported across included studies. Provision of adequate resources was the most frequently identified enabler to sustainability (n/N = 9/12, 75%); however, relatively few studies (n = 4) provided a robust report of determinants, with no study reporting determinants of sustainability and strategies and adaptations to support sustainability alongside patient and service delivery outcomes.

CONCLUSION

Improved reporting, particularly of strategies and adaptations to support sustainability is needed. Refinement of ERAS reporting guidelines should be made to facilitate this, and future implementation studies should plan to document and report changes in context and corresponding programme changes to help researchers and clinicians sustain ERAS programmes locally.

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States.

METHODS

PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients.

RESULTS

53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included.

CONCLUSIONS

AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study

BACKGROUND

Adherence to enhanced recovery after surgery (ERAS) protocols is crucial for successful liver surgery. The aim of this study was to assess the impact of minimally invasive liver surgery complexity on adherence after implementing an ERAS protocol.

METHODS

Between July 2018 and August 2021, a prospective observational study involving minimally invasive liver surgery patients was conducted. Perioperative treatment followed ERAS guidelines and was recorded in the ERAS interactive audit system. Kruskal-Wallis and ANOVA tests were used for analysis, and pairwise comparisons utilized Wilcoxon rank sum and Welch's t-tests, adjusted using Bonferroni correction.

RESULTS

A total of 243 patients were enrolled and categorized into four groups based on the Iwate criteria: low (n = 17), intermediate (n = 81), advanced (n = 74) and expert difficulty (n = 71). Complexity correlated with increased overall and major morbidity rate, as well as longer length of stay (all P < 0.001; standardized mean difference = 0.036, 0.451, 0.543 respectively). Adherence to ERAS measures decreased with higher complexity (P < 0.001). Overall adherence was 65.4%. Medical staff-centred adherence was 79.9%, while patient-centred adherence was 38.9% (P < 0.001). Complexity significantly affected patient-centred adherence (P < 0.001; standardized mean difference (SMD) = 0.420), but not medical staff-centred adherence (P = 0.098; SMD = 0.315). Postoperative phase adherence showed major differences among complexity groups (P < 0.001, SMD = 0.376), with mobilization measures adhered to less in higher complexity cases.

CONCLUSION

The complexity of minimally invasive liver surgery procedures impacts ERAS protocol adherence for each patient. This can be addressed using complexity-adjusted cut-offs and 'gradual adherence' based on the relative proportion of cut-off values achieved.

Transforming Bariatric Surgery Outcomes: The Pivotal Role of Enhanced Recovery After Surgery (ERAS) Protocols in Patient-Centered Care

Bariatric surgery is a critical strategy in managing morbid obesity. Enhanced recovery after surgery (ERAS) protocols have revolutionized perioperative care in this field. This systematic review aims to synthesize current evidence on the impact of ERAS protocols on patient-centered outcomes in bariatric surgery. A comprehensive search across multiple databases was conducted, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies involving adult patients undergoing bariatric surgery and focusing on the implementation and outcomes of ERAS protocols were included. Data extraction and analysis emphasized patient recovery, well-being, and satisfaction. Eleven studies met the inclusion criteria. The review revealed that ERAS protocols are associated with reduced postoperative recovery times, decreased hospital stays, and enhanced patient satisfaction. Notably, ERAS protocols effectively reduced complications and optimized resource utilization in bariatric surgery. Comparative insights from non-bariatric surgeries highlighted the versatility and adaptability of ERAS protocols across different surgical disciplines. ERAS protocols significantly improve patient-centered outcomes in bariatric surgery. Their adoption facilitates a patient-focused approach, accelerating recovery and enhancing overall patient well-being. The findings advocate for the broader implementation of ERAS protocols in surgical care, emphasizing the need for continuous refinement to meet evolving healthcare demands. This review supports the paradigm shift toward integrating ERAS protocols in bariatric surgery and potentially other surgical fields.

Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries

BACKGROUND

Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor.

METHODS

We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use.

RESULTS

A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014).

CONCLUSIONS

We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Intravascular volume status and stress markers in patients observing long and short duration of fasting: A prospective single blinded observational study

BACKGROUND

Preoperative fasting may lead to intravascular volume depletion and this volume depletion may be a cause of perioperative stress. This study intends to compare the levels of stress markers in patients undergoing long and short duration fasting before an elective laparoscopic surgery.

METHOD

This was a single blind, observational study. Based on the duration of fasting, 70 ASA I and II category patients undergoing elective laparoscopic cholecystectomy(LC) were divided into two groups of 35 patients each. If the surgeon had prescribed a fasting since midnight then patient was considered for inclusion in Long fasting (LF) group; if surgeon had allowed clear fluids till 2 h before surgery then the patient was considered for inclusion in the short fasting(SF) group. The extent of intravascular volume depletion was measured using inferior vena cava collapsibility index (IVCCI). Levels of relevant stress markers i.e. cortisol, Tetraiodothyronine (FT4), C-peptide, C-reactive protein(CRP) and blood glucose (BGL) were measured at 8 PM in the night before surgery, at 7 AM on the day of surgery, 2 h after the surgery and 24 h after the surgery.

RESULT

IVCCI was significantly more in the LF group; 27.66 ± 3.34% vs17.83 ± 2.22%, 95% CI 8.47-11.18, P-value <0.001). IVCCI had a significant correlation with the duration of fasting, Pearson's correlation r = 0.69,P-value <0.001. Repeated measures ANCOVA revealed that CRP, Free T4 and C-peptide levels got significantly elevated over the study duration, P-values <0.001,<0.001 and 0.03 respectively but with IVCCI, Age and Gender as the covariates, the increase in the levels of CRP, Free T4 and C-peptide were similar in both the groups.

CONCLUSION

Stress markers levels show significant elevation in the perioperative period, maximum over the study duration, but this change is similar in both the groups.

CLINICAL TRIAL NO

CTRI/2021/02/031456.

Enhanced recovery after surgery in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: national survey of peri-operative practice by Indian society of peritoneal surface malignancies

Objectives

The Enhanced recovery after surgery (ERAS) program is designed to achieve faster recovery by maintaining pre-operative organ function and reducing stress response following surgery. A two part ERAS guidelines specific for Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was recently published with intent of extending the benefit to patients with peritoneal surface malignancies. This survey was performed to examine clinicians' knowledge, practice and obstacles about ERAS implementation in patients undergoing CRS and HIPEC.

Methods

Requests to participate in survey of ERAS practices were sent to 238 members of Indian Society of Peritoneal Surface malignancies (ISPSM) via email. They were requested to answer a 37-item questionnaire on elements of preoperative (n=7), intraoperative (n=10) and postoperative (n=11) practices. It also queried demographic information and individual attitudes to ERAS.

Results

Data from 164 respondents were analysed. 27.4 % were aware of the formal ERAS protocol for CRS and HIPEC. 88.4 % of respondents reported implementing ERAS practices for CRS and HIPEC either, completely (20.7 %) or partially (67.7 %). The adherence to the protocol among the respondents were as follows: pre operative (55.5-97.6 %), intra operative (32.6-84.8 %) and post operative (25.6-89 %). While most respondents considered implementation of ERAS for CRS and HIPEC in the present format, 34.1 % felt certain aspects of perioperative practice have potential for improvement. The main barriers to implementation were difficulty in adhering to all elements (65.2 %), insufficient evidence to apply in clinical practice (32.4 %), safety concerns (50.6 %) and administrative issues (47.6 %).

Conclusions

Majority agreed the implementation of ERAS guidelines is beneficial but are followed by HIPEC centres partially. Efforts are required to overcome barriers like improving certain aspects of perioperative practice to increase the adherence, confirming the benefit and safety of protocol with level I evidence and solving administrative issues by setting up dedicated multi-disciplinary ERAS teams.

ERAS programme in a Portuguese tertiary hospital: An audit of the first six months of implementation in elective colorectal surgery

INTRODUCTION AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) is a multimodal strategy designed to optimize postoperative recovery and reduce morbidity, length of hospital stay, and care costs. The aim of this study was to evaluate compliance and clinical outcomes 6 months of implementation of the program in scheduled colorectal surgery in a tertiary hospital.

MATERIAL AND METHODS

Data from 209 patients who underwent elective colorectal surgery were analysed. The first 102 patients (pre-ERAS group) who underwent surgery between January and May 2018, before the implementation of the program, were compared with the 107 patients treated between May and October 2019, after ERAS implementation. The main outcomes were patient education and counselling, use of intravenous fluids, early mobilization, incidence of postoperative nausea and vomiting, return of bowel function, length of stay, complications, mortality, and overall compliance.

RESULTS

The ERAS program was associated with a significant increase in patient education and counselling (p<0.001) and with a significant reduction in intra- and postoperative IV fluid administration (p=0.007 and p<0.001, respectively) and postoperative nausea or vomiting (17.6% vs 5.0%, p=0.007). Time to recovery of activities of daily living (5.29 vs 2.85 days; p<0.001), time to solid oral intake (6.21 vs 4.35 days; p<0.001), time to first flatus (2.41 vs 1.51 days; p<0.001) and defecation (3.35 vs 1.66 days; p<0.001) decreased with ERAS. There were no statistically significant differences in length of stay, complications, and mortality.

CONCLUSION

This study showed that the ERAS program improved perioperative outcomes and postoperative recovery in patients undergoing colorectal surgery in our hospital.

High adherence to enhanced recovery pathway independently reduces major morbidity and mortality rates after colorectal surgery: a reappraisal of the iCral2 and iCral3 multicenter prospective studies

Background:

Enhanced recovery after surgery (ERAS) offers lower overall morbidity rates and shorter hospital stay after colorectal surgery (CRS); high adherence rates to ERAS may significantly reduce major morbidity (MM), anastomotic leakage (AL), and mortality (M) rates as well.

Methods:

Prospective enrollment of patients submitted to elective CRS with anastomosis in two separate 18- and 12-month periods among 78 surgical centers in Italy from 2019 to 2021. Adherence to ERAS pathway items was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints (MM, AL, and M rates) were identified through logistic regression analyses, presenting odds ratios (OR) and 95% confidence intervals.

Results:

An institutional ERAS status was declared by 48 out of 78 (61.5%) participating centers. The median overall adherence to ERAS was 75%. Among 8,359 patients included in both studies, MM, AL, and M rates were 6.3%, 4.4%, and 1.0%, respectively. Several patient-related and treatment-related variables showed independently higher rates for primary endpoints: male gender, American Society of Anesthesiologists class III, neoadjuvant treatment, perioperative steroids, intra- and/or postoperative blood transfusions, length of the operation >180’, surgery for malignancy. On the other hand, ERAS adherence >85% independently reduced MM (OR, 0.91) and M (OR, 0.25) rates, whereas no mechanical bowel preparation independently reduced AL (OR, 0.68) rates.

Conclusions:

Among other patient- or treatment-related variables, ERAS adherence >85% independently reduced MM and M rates, whereas no mechanical bowel preparation independently reduced AL rates after CRS.

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis

Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

OBJECTIVES

To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.

METHODS

This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3.

RESULTS

A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02).

CONCLUSIONS

Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.

ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report

BACKGROUND

Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached.

METHODS

The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications' occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item.

RESULTS

1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery.

CONCLUSIONS

Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations

BACKGROUND

Few data are available on discharge criteria after living liver donation (LLD).

OBJECTIVES

To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725).

RESULTS

Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively.

CONCLUSIONS

Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).

ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report

Background

Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached.

Methods

The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item.

Results

1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery.

Conclusions

Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

The orange-III study: the use of preoperative laxatives prior to liver surgery in an enhanced recovery programme, a randomized controlled trial

BACKGROUND

This study evaluates the effect of preoperative macrogol on gastrointestinal recovery and functional recovery after liver surgery combined with an enhanced recovery programme in a randomized controlled setting.

METHODS

Patients were randomized to either 1 sachet of macrogol a day, one week prior to surgery versus no preoperative laxatives. Postoperative management for all patients was within an enhanced recovery programme. The primary outcome was recovery of gastrointestinal function, defined as Time to First Defecation. Secondary outcomes included Time to Functional Recovery.

RESULTS

Between August 2012 and September 2016, 82 patients planned for liver resection were included in the study, 39 in the intervention group and 43 in the control group. Median Time to First Defecation was 4.0 days in the intervention group (IQR 2.8-5.0) and 4.0 days in the control group (IQR 2.9-5.0), P = 0.487. Median Time to Functional Recovery was day 6 (IQR 4.0-8.0) in the intervention group and day 5 (IQR 4.0-7.5) in the control group, P = 0.752. No significant differences were seen in complication rate, reinterventions or mortality.

CONCLUSION

This randomized controlled trial showed no advantages of 1 sachet of macrogol preoperatively combined with an enhanced recovery programme, for patients undergoing liver surgery.

Enhanced recovery after surgery in liver transplantation: Challenges and feasibility

BACKGROUND

Enhanced recovery after surgery (ERAS) started a revolution that changed age-old surgical stereotypical practices regarding the overall management of the surgical patient. In the last decade, ERAS has gained significant acceptance in the community of general surgery, in addition to several other surgical specialties, as the evidence of its advantages continues to grow. One of the last remaining fields, given its significant complexity and intricate nature, is liver transplantation (LT).

AIM

To investigate the existing efforts at implementing ERAS in LT.

METHODS

We conducted a systematic review of the existing studies that evaluate ERAS in orthotopic LT, with a multimodal approach and focusing on measurable clinical primary endpoints, namely length of hospital stay.

RESULTS

All studies demonstrated a considerable decrease in length of hospital stay, with no readmission or negative impact of the ERAS protocol applied to the postoperative course.

CONCLUSIONS

ERAS is a well-validated multimodal approach for almost all types of surgical procedures, and its future in selected LT patients seems promising, as the preliminary results advocate for the safety and efficacy of ERAS in the field of LT.

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

The current and future role of nurses within enhanced recovery after surgery pathways

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research.

DISCUSSION

Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy.

CONCLUSION

Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.

Enhanced recovery after surgery protocols for outpatient operations in otolaryngology: Review of literature

Objective

Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based pathways designed to reduce complications, promote recovery, and improve outcomes following surgery. These protocols have been successfully applied for the management of head and neck cancer, but relatively few studies have investigated the applicability of these pathways for other outpatient procedures in otolaryngology. Our goal was to perform a systematic review of available evidence reporting the utility of ERAS protocols for the management of patients undergoing outpatient otolaryngology operations.

Methods

A systematic literature review was conducted using MEDLINE, EMBASE, SCOPUS, and gray literature. We identified studies that evaluated ERAS protocols among patients undergoing otologic, laryngeal, nasal/sinus, pediatric, and general otolaryngology operations. We assessed the outcomes and ERAS components across protocols as well as the study design and limitations.

Results

A total of eight studies fulfilled the inclusion criteria and were included in the analysis. Types of procedures evaluated with ERAS protocols included tonsillectomy and adenoidectomy, functional endoscopic sinus surgery, tympanoplasty and mastoidectomy, and septoplasty. A reduction in postoperative length of stay and hospital costs was reported in two and three studies, respectively. Comparative studies between ERAS and control groups showed persistent improvement in pre- and postoperative anxiety and pain levels, without an increase in postoperative complications and readmission rates.

Conclusions

A limited number of studies discuss implementation of ERAS protocols for outpatient operations in otolaryngology. These clinical pathways appear promising for these procedures as they may reduce length of stay, decrease costs, and improve pain and anxiety postoperatively.

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

BACKGROUND

Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

METHODS

Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

RESULTS

Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049).

CONCLUSIONS

This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

The Global States and Hotspots of ERAS Research From 2000 to 2020: A Bibliometric and Visualized Study

Background

Enhanced recovery after surgery (ERAS) protocol has been implemented in surgeries for more than 20 years, this study investigated the global states and hotspots of ERAS research.

Methods

Based on the Web of Science database, a bibliometric and visualized study of original ERAS research from 2000 to 2020 was performed, including the trends of publications and citations; distribution of countries, authors, institutions, sources; study design, level of evidence, served surgeries and surgical disciplines. Hotspots were revealed by research interests and keywords.

Results

Within the field of original ERAS research, there was a rising trend in annual publications and citations. The USA was the greatest contributor. Kehlet, H, University of Copenhagen were the most influential author and institution, respectively. British Journal of Surgery and Annals of Surgery were the most cited journals. Though there were more prospective designs, more than half of the studies presented level IV evidence and had fewer citations and citation densities compared to that of level II and level III. ERAS protocol was overwhelmingly implemented in colorectal surgeries. Most studies focused on elements of ERAS, the top three research interests were “length of stay,” “pain management,” and “complications.” In recent years, bariatric surgery, compliance with ERAS, and feasibility in the elderly were new hotspots.

Conclusion

Revealing the global states and hotspots can help researchers better understand the trends in ERAS research. The USA was the greatest contributor to ERAS research. Kehlet, H, was the most influential author in the field. Bariatric surgery, compliance with ERAS, and feasibility in the elderly represent the new trend of ERAS research. Most of the ERAS research had a low evidence levels, studies with high-level evidence are still required in this field.

Enhanced recovery protocols in patients undergoing pancreatic surgery: An umbrella review

AIM

To identify, synthesize and appraise the systematic reviews of ERAS for patients undergoing pancreatic surgery and facilitate ERAS implementation.

DESIGN

An umbrella review was used to identify systematic reviews.

METHODS

A systematic search following the PRISMA guidelines was used to search databases including PubMed, Embase, Cochrane Library, CINAHL, CNKI, WanFang and VJIP. AMSTAR 2 was used to appraise the quality of included reviews.

RESULTS

Ten systematic reviews were included. The quality of all included systematic reviews was rated as "critically low." The most frequently reported ERAS elements were epidurals analgesia/PCA (9/10), goal-directed mobilization (9/10) and early removal of drains (9/10). Only one review mentioned audit protocol compliance. None of the included reviews reported discharge standards. Ten reviews reported decreased length of stay, seven reviews reported lower hospital costs, and six reviews reported decreased total complications rate. There were no adverse effects reported.

[First 18 months as certified ERAS® center for colorectal cancer : Lessons learned and results of the first 261 patients]

BACKGROUND

Enhanced recovery after surgery (ERAS®) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.

GOAL OF THE WORK

The aim of this article is to present the experiences of our center certified by the ERAS® Society for colorectal resections 18 months after successful implementation.

MATERIAL AND METHODS

Since the beginning of the certification 261 patients have been treated in our clinic according to the specifications of the ERAS® concept. As a comparison group the last 50 patients prior to implementation were evaluated in terms of compliance with ERAS® requirements, length of hospital stay and readmission rate, the need for care in an intensive or intermediate care ward, the number of necessary reoperations and the complication rate.

RESULTS

Compliance increased from 39.3% preERAS® to 81.1% after ERAS® implementation (p < 0.001). At the same time the length of stay of ERAS® patients was reduced from 7 days to 5 days (p = 0.001). While the rate of surgical complications was the same between the two groups (p = 0.236), nonsurgical complications occurred significantly less frequently in the ERAS® cohort (p = 0.018).

DISCUSSION

There are well-known stumbling blocks in implementing and maintaining an ERAS® concept; however, it is worthwhile for the patient to circumnavigate this and establish ERAS® as the standard treatment path.