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

Prophylactic drain placement versus non-drainage following gastric cancer surgery: A systematic review and meta-analysis of randomized controlled trials

Gastric cancer remains a significant global health burden and a leading cause of cancer-related deaths. Surgical resection is the primary curative treatment, but postoperative complications can negatively impact outcomes. Prophylactic drainage (PD) has been widely used to reduce these complications by facilitating early detection and management of fluid collections. This study evaluates the role of PD following gastric cancer surgery through a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched PubMed, Web of Science, Scopus, and Cochrane databases up to January 15, 2025, and analyzed dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), both with 95 % confidence intervals (CI), using R version 4.3 (PROSPERO ID: CRD42025650045). Four RCTs involving 728 patients were included. The analysis revealed that PD was associated with a significantly lower risk of mortality compared to no drainage (RR: 0.45 [95 % CI: 0.21-0.94]; P = 0.03). However, there were no significant differences between the drainage and non-drainage groups in the incidence of intra-abdominal abscess (RR: 1.23 [95 % CI: 0.49-3.06]; P = 0.66), surgical-site infection (RR: 0.93 [95 % CI: 0.56-1.52]; P = 0.76), pulmonary infection (RR: 0.66 [95 % CI: 0.37-1.18]; P = 0.16), duodenal stump leakage (RR: 1.54 [95 % CI: 0.51-4.71]; P = 0.45), anastomotic leakage (RR: 1.47 [95 % CI: 0.64-3.39]; P = 0.37), or reoperation rates (RR: 0.95 [95 % CI: 0.40-2.27]; P = 0.90). Additionally, no significant differences were observed in the length of hospital stay (MD: 0.10 [95 % CI: -0.39 to 0.58]; P = 0.70) or time to the first soft diet (MD: 0.21 [95 % CI: -0.09 to 0.50]; P = 0.17). In conclusion, PD following gastric cancer surgery is associated with a reduced risk of mortality but does not significantly impact the incidence of perioperative complications or recovery metrics. These findings suggest that while PD may offer a survival benefit, it does not appear to reduce common postoperative complications or accelerate recovery.

Clinical value of preoperative oral carbohydrate loading in patients with diabetes: a cross-sectional study

Background

Preoperative oral carbohydrate loading (POCL) has shown benefits in non-diabetic patients, but its use in patients with diabetes remains controversial. Concerns about potential hyperglycemia and adverse outcomes have led to conflicting evidence and varied clinical practices.

Objective

To assess the impact of POCL on clinical outcomes after surgery in patients with diabetes.

Methods

This retrospective study analyzed 679 patients with diabetes undergoing elective surgery from 2020 to 2023, divided into POCL and fasting groups. After 1:1 propensity score matching (PSM), 410 patients were analyzed. Primary outcomes included postoperative blood glucose levels; secondary outcomes were including glycemic variability, pulmonary infections, hospital stay length, and costs.

Results

After PSM, POCL was associated with significantly lower blood glucose levels on the first postoperative day compared to the fasting group (11.03 [9.43–12.77] vs. 11.37 [9.77–13.20], P  = 0.045). No significant differences were observed in glycemic variability. POCL patients demonstrated shorter postoperative hospital stays (5.10 [3.00-7.70] vs. 5.90 [3.80–8.50], P  = 0.022). Multivariate analysis revealed that POCL independently predicted reduced hospitalization costs (β=-3417.49, 95% CI [-6358.52, -476.46], P  = 0.023) and shorter hospital stays (β=-1.21, 95% CI [-1.83, -0.60], P  < 0.001). Higher ASA scores and longer surgical durations were associated with increased costs, while prolonged surgeries correlated with greater pulmonary infection risk (OR = 1.005, 95% CI [1.003–1.008], P  < 0.001).

Conclusion

Despite previous concerns, POCL appears to be associated with lower early postoperative blood glucose levels, shorter hospital stays, and reduced costs in patients with well-controlled diabetes (HbA1c < 7.5%). It may be a safe and effective perioperative strategy for this specific population, though individualized assessment remains essential.

Monitoring early discharge after laparoscopic colon surgery: an interventional study

BACKGROUND

Laparoscopic colorectal surgery combined with Enhanced Recovery after Surgery (ERAS) has improved patient outcomes by promoting faster recovery, reducing pain, and lowering the risk of complications. However, increasing demand on hospital capacity for clinical admissions and the shortage of healthcare professionals remains challenging. Home monitoring after surgical procedures and early discharge offers a potential solution. This study aims to assess the feasibility, safety and patient satisfaction with early discharge following elective colorectal surgery using continuous monitoring of vital signs and questionnaires.

METHODS

A prospective, single-centre, interventional study. Patients who meet the discharge criteria could leave on day one or two after surgery, monitored at home with sensors for vital signs and health questionnaires.

RESULTS

Of 51 patients, 30 (58.8%) were discharged early. The results show successful early discharge in 80% (24 out of 30 patients) with a readmission rate of 20% of which 13.3% due to problems with the monitoring system. None of these readmissions were due to deviations in vital sign measurement at home. The patient satisfaction was high ranging between 6 and 7 (out of 7).

CONCLUSION

Early discharge with continue monitoring is feasible for a selected group of colorectal surgery patients. No patients were readmitted because of serious complications. Further research should focus on expending the sample size and investigating the impact of early discharge without continuous monitoring.

Lidocaine-A Promising Candidate for the Treatment of Cancer-Induced Bone Pain: A Narrative Review

Pain is one of the most common symptoms in patients with cancer, with cancer-induced bone pain (CIBP) significantly affecting their quality of life. Opioids are commonly used as first-line treatments for cancer pain, but their use requires caution due to non-mechanistic analgesia and significant side effects. As a result, there is a need for new non-opioid drugs that target cancer pain through specific mechanisms. Recent studies on the anticancer effects of lidocaine have highlighted its potential benefits in both treating cancer and alleviating cancer-induced pain. This article discusses the mechanism of action and clinical applications of lidocaine in cancer pain management, and suggests new treatment approaches for patients with CIBP.

Surgical outcomes of colorectal cancer surgery in transplant recipients: A matched case-control study

AIM

The incidence of colorectal carcinoma (CRC) in transplant (TX) recipients is higher than in the general population. Registry data indicate inferior oncological outcomes for this population. While the general surgical risk is increased in TX recipients, the risk associated with elective CRC surgery in this population is not well investigated.

METHODS

TX recipients, who underwent elective surgical treatment for CRC at our specialized centre from 2008 to 2024 were included in this case-control study. The controls were randomly selected from our CRC database and matched according to tumour location and Charlson Comorbidity Index. Outcomes assessed included intensive care unit stay, in-hospital mortality, length of hospital stay and major morbidity (defined as Clavien-Dindo Grade ≥3).

RESULTS

The study included 24 TX recipients. Ten patients had had either liver or kidney TX, three patients had undergone lung TX and one patient heart TX. The mean time interval between transplantation surgery and CRC was 8.82 years. Morbidity was significantly higher in the TX group (54.2% vs. 8.3%, P = 0.001; OR 13.0, 95% CI 2.5-68,1, P = 0.002) and length of hospital stay was significantly longer (25 vs. 9 days, P = 0.001; OR 9.09, 95% CI 1.4-16.7, P = 0.022) for TX patients. No significant differences in mortality and intensive care unit stay were observed.

CONCLUSIONS

The risk of surgery for CRC in TX patients is significantly increased. Treatment decisions should involve TX experts to develop a tailored and considered treatment plan.

The enhanced recovery after surgery protocol in paediatric surgery: The analysis of the protocol principles based on a survey among Polish clinical centres

INTRODUCTION

The enhanced recovery after surgery (ERAS) protocol is a complex set of measures that improves patient outcomes in the adult population. The main goal of the protocol is to sustain homeostasis by mitigating the metabolic stress induced by surgical procedures. Hence, the search for similar solutions in paediatric patients since the benefits in the paediatric population are less well known.

MATERIAL AND METHODS

The principles of the ERAS protocol were presented. A questionnaire survey was prepared to assess the preparation for the implementation of ERAS in paediatric surgery departments. Heads of all 19 clinical centres from Poland providing colorectal surgery in children were invited to participate. Seven centres responded to the survey. The questionnaire included four general questions related to the familiarity with ERAS and specific questions about the implementation of the 23-item protocol.

RESULTS

Five centres confirmed familiarity with the principles of the protocol and two of them confirmed the use of ERAS. The lowest number of implemented procedures was six, while the highest number was 18 out of 23. No centre implemented the zero fluid balance strategy. However, as many as five of the seven centres avoided preoperative fasting, three centres avoided mechanical bowel preparation, and three respondents used early oral nutrition in the postoperative period.

CONCLUSIONS

The ERAS protocol is commonly used and accepted worldwide. Other surgical teams may use the information contained in the manuscript to create or improve their ERAS protocol.

90-day mortality prediction in elective visceral surgery using machine learning: a retrospective multicenter development, validation, and comparison study

BACKGROUND

Machine Learning (ML) is increasingly being adopted in biomedical research, however, its potential for outcome prediction in visceral surgery remains uncertain. This study compares the potential of ML methods for preoperative 90-day mortality (90DM) prediction of an aggregated multi-organ approach to conventional scoring systems and individual organ models.

METHODS

This retrospective cohort study enrolled patients undergoing major elective visceral surgery between 2014 and 2022 across two tertiary centers. Multiple ML models for preoperative 90DM prediction were trained, externally validated and benchmarked against the American Society of Anesthesiologists (ASA) score and revised Charlson Comorbidity Index (rCCI). Areas under the receiver operating characteristic (AUROC) and precision recall curves (AUPRC) including standard deviations were calculated. Additionally, individual models for esophageal, gastric, intestinal, liver, and pancreatic surgery were developed and compared to an aggregated approach.

RESULTS

7711 cases encompassing 78 features were included. Overall 90DM was 4% (n = 309). An XBoost classifier demonstrated the best performance and high robustness following external validation (AUROC: 0.86 [0.01]; AUPRC: 0.2 [0.04]). All models outperformed the ASA score (AUROC: 0.72; AUPRC: 0.08) and rCCI (AUROC: 0.81; AUPRC: 0.11). rCCI, patient age and C-reactive protein emerged as most decisive model weights. Models for gastric (AUROC: 0.88 [0.13]; AUPRC: 0.24 [0.26]) and intestinal surgery (AUROC: 0.87 [0.05]; AUPRC: 0.17 [0.09]) revealed the highest organ-specific performances, while pancreatic surgery yielded the lowest results (AUROC: 0.66 [0.08]; AUPRC: 0.22 [0.12]). A combined multi-organ approach (AUROC: 0.84 [0.04]; AUPRC: 0.21 [0.06]) demonstrated superiority over the weighted average across all organ-specific models (AUROC: 0.82 [0.07]; AUPRC: 0.2 [0.13]).

CONCLUSION

ML offers robust preoperative risk stratification for 90DM in elective visceral surgery. Leveraging training across multi-organ cohorts may improve accuracy and robustness compared to organ-specific models. Prospective studies are needed to confirm the potential of ML in surgical outcome prediction.

Preoperative carbohydrate loading reduces length of stay after major elective, non-cardiac surgery when compared to fasting: a systematic review and meta-analysis

Preoperative fasting is a worldwide routine even though the most recent Enhanced Recovery After Surgery (ERAS) Guidelines recommend preoperative carbohydrate loading instead of fasting, but with low quality of evidence. Our aim was to compare the effects of preoperative carbohydrate loading to fasting and placebo in patients undergoing elective major non-cardiac surgery under general anaesthesia. Our systematic search was conducted on 15th of October 2021 in five databases, Medline, Embase, Central, Web of Science and Scopus, and updated on November 12th, 2024. We included randomized controlled trials that compared the carbohydrate loading (CHO-group) with fasting or with placebo. Main outcomes were length of hospital stay (LOS), postoperative glucose levels on postoperative, postoperative insulin levels, and C-reactive protein (CRP) levels. Our search revealed 44 eligible articles for data extraction. LOS was shorter in the CHO group as compared to the No-CHO group (MD: - 0.56 [95% CI: - 1.10, - 0.02]). There were no clinically significant differences between the CHO and No-CHO groups regarding the postoperative glucose, insulin and CRP levels. This meta-analysis found that preoperative CHO-loading as compared to preoperative fasting or placebo shortened the length of hospital stay in patients undergoing major elective, non-cardiac surgery. Although several details are still to be unveiled, these data provide further support that preoperative carbohydrate loading could be beneficial in this patient population.

Safety and efficacy of gastrointestinal motility agents following elective colorectal surgery: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Postoperative ileus (POI) is a frequent complication after elective colorectal surgery, delaying gastrointestinal (GI) recovery and discharge. While pharmacologic agents such as laxatives and prokinetics are often included in enhanced recovery after surgery (ERAS) protocols, their efficacy and safety remain uncertain.

METHODS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to evaluate the effect of Gastrointestinal (GI) motility agents on postoperative recovery in elective colorectal surgery. Primary outcomes included GI-2 recovery (tolerance of solid diet and stool passage), time to first defaecation, and safety endpoints. Data was pooled using random-effects models.

RESULTS

Seven RCTs involving 849 patients were included. GI motility agents significantly accelerated GI-2 recovery (mean difference -1.01 days; 95% CI -1.29 to -0.73; p < 0.001) and reduced time to first defaecation (mean difference -1.07 days; 95% CI -1.40 to -0.73; p < 0.001). No significant differences were observed in safety outcomes, including anastomotic leak (OR 0.97; 95% CI 0.53 to 1.77), nasogastric tube reinsertion (OR 0.86; 95% CI 0.49 to 1.51), or readmission rates (OR 1.03; 95% CI 0.62 to 1.72).

CONCLUSION

Motility agents enhance postoperative GI recovery without compromising safety in patients undergoing elective colorectal surgery. Given their low cost, wide availability, and favourable safety profile, gastrointestinal motility agents may be considered for integration into ERAS protocols. However, further high-quality, standardised trials are needed to confirm their benefits across diverse surgical populations.

Early mobilization in postoperative glioma patients real world impact on recovery and long term prognosis

The implementation of early mobilization in postoperative care has been shown to expedite patient recovery. However, its widespread use among patients undergoing glioma resection is not firmly established. This study aimed to implement an early mobilization protocol in glioma patients and evaluate its effects on early recovery and long-term prognosis. Patients who underwent craniotomy for glioma treatment between January 2018 and December 2019 were enrolled in a randomized controlled trial comparing conventional perioperative care (control group) with conventional care plus a structured early mobilization protocol (experimental group). We collected data on early recovery and long-term prognosis from patients' electronic health records. Means and frequencies were evaluated using the Mann-Whitney U test, T-test, and chi-square test. The research team conducted standardized assessments in advance to ensure consistency. Postoperative primary outcomes revealed that the experimental group showed improvements of 39.06 points in activities of daily living and 0.86 points in numerical rating scale scores for pain, a 2.02 day shorter mean length of hospital stay (95% confidence interval [CI] 91.099-100.596, 0.403-1.691, 9.754-15.060, P < 0.001). Secondary outcomes also indicated that the experimental group had a 4.2 day shorter mean time to ambulation, a 3.48 day shorter mean duration of central venous catheter use, a 4.15 day shorter mean duration of gastric tube use, and a 3.64 day shorter mean duration of urethral catheter use. Furthermore, the experimental group demonstrated a significantly lower incidence of postoperative complications and reduced hospitalization expenses (P < 0.05). However, no statistically significant differences with secondary outcomes were observed in intraoperative blood loss or three-year prognosis between the two groups. Our findings show that an early mobilization protocol can promote early recovery in patients undergoing glioma resection without adversely affecting long-term prognosis. The protocol demonstrated both safety and cost-effectiveness, supporting its clinical implementation to improve postoperative functional recovery.

Current state and future education implication of enhanced recovery after surgery (ERAS) among Chinese anesthesiologists: national repeated cross-sectional surveys from 2019 to 2023

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been widely adopted to improve surgical outcomes. In this study, we aimed to assess the current state of awareness and specific knowledge of ERAS among Chinese anesthesiologists, examine difficulties in implementation, and identify future priorities for ERAS education and training.

METHODS

A self-designed, repeated national survey regarding awareness and practice of the ERAS concept, specific knowledge, learning modalities, and difficulties in ERAS implementation was conducted in 2019, 2021, and 2023. Factors related to mastery of knowledge were analyzed via subgroup analysis and multivariable linear regression.

RESULTS

A total of 6385 participants were included; 96.2% were anesthesiologists. Approximately half of the participants reported implementing ERAS in more than 40% of patients. Compared with those in the 2019 survey, the overall proportion of participants who had heard about the concept of ERAS remained relatively stable across the three surveys (P = 0.078). However, significant improvements were observed in participants reported good understanding (defined as responding "very familiar" or "quite familiar") of ERAS and implementing rate of ERAS in clinical practice (P < 0.001). The mean score on the 15-question quiz was 8.5 ± 2.5. Significant differences in scores were observed across various geographic regions, levels of hospitals, education, professional titles, and age. Most anesthesiologists expressed a strong desire for additional education on ERAS in several ways. Feedback from the open-ended question in the survey indicated that multidisciplinary collaboration was a major challenge in implementing ERAS.

CONCLUSIONS

This nationwide study indicates a notable enhancement in the comprehension and implementation of ERAS among Chinese anesthesiologists, although there is still room for improvement. Future efforts should focus on improving education and training to enhance ERAS knowledge and practice levels among health care providers.

CLINICAL TRIAL NUMBER

Not applicable.

Longitudinal Trajectory of Patient-Reported Fatigue in Patients Undergoing Thoracoscopic Lung Cancer Surgery

BACKGROUND

Postoperative fatigue is widely recognized as one of the most prevalent adverse effects of surgery, representing a critical determinant of functional recovery and quality of life. However, fatigue is commonly measured at a single time point, failing to capture its dynamic nature. This study aimed to characterize the longitudinal trajectories of postoperative fatigue and identify the potential factors.

METHODS

This retrospective study included patients with lung cancer who underwent thoracoscopic surgery between March 2021 and October 2023. Patients completed the Perioperative Symptom Assessment for Lung Surgery Scale (PSA-Lung) daily for 7 days after surgery. Latent class mixed modeling was used to analyze the longitudinal patient-reported data and identify subgroups based on trajectory features.

RESULTS

A total of 1,096 patients were included. Three-cluster trajectory model provided the best fit, consisting of deterioration-fatigue group (17.7%), recovery-fatigue group (31.4%) and mild-fatigue group (50.9%). Compared with the mild-fatigue group, patients with comorbidities had a higher risk of being categorized into the recovery-fatigue group (odds ratio 1.44, 95% confidence interval 1.02-2.04; p = 0.040). The presence of recovery-fatigue was associated with lower preoperative hemoglobin level (p = 0.025). Moreover, lower preoperative body mass index and albumin level increased the likelihood of being classified as the deterioration-fatigue group (p = 0.022 and p = 0.026, respectively).

CONCLUSIONS

This study elucidated the heterogeneity of fatigue trajectories, with half of the patients experiencing either recovery-fatigue or deterioration-fatigue. The severity of postoperative fatigue was found to be worse in patients with comorbidities or poor nutritional status.

Barriers and facilitators to prehabilitation of elderly patients with early lung cancer from the perspective of different clinical professionals: a qualitative study

BACKGROUND

Understanding the barriers and facilitators of prehabilitation in elderly patients with early-stage lung cancer is of significant importance. This study aimed to elucidate these barriers and facilitators from the perspectives of different clinical professionals.

METHODS

A qualitative descriptive study was undertaken. Semi-structured interviews with clinical professionals, using purposive sampling and content analysis were conducted in March to May 2023 to summarize and refine the key themes.

RESULTS

From the perspective of clinical professionals, the facilitators of prehabilitation have been categorized into five major themes. These include the recognized importance of prehabilitation, the positive attitude of clinical professionals, the support of leadership, the willingness of the majority of patients to accept prehabilitation, and the initial implementation of an enhanced recovery after surgery - multidisciplinary team (ERAS-MDT) approach. Conversely, clinical professionals identify several barriers to prehabilitation, which are grouped into seven themes. These impediments encompass a lack of knowledge regarding clinical practice, insufficient preoperative preparation time, the absence of an aging-friendly clinical practice scheme, an immature multidisciplinary cooperation mechanism, a lack of explicit regulations, inadequate emergency safeguards, and a shortage of specialized professionals. Practice strategies for promoting prehabilitation in elderly patients with early lung cancer include development of evidence summaries, develop healthcare training materials, develop patient health education brochures, clarify the division of labor of ERAS-MDT, improve patient safety and monitoring measures, optimize practice flow and obtain funding support.

CONCLUSION

To enhance the feasibility and clinical relevance of prehabilitation, clinical professionals should consider establishing a multidisciplinary information consulting team, developing a comprehensive prehabilitation program, and reinforcing the support system prior to surgery.

European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic abdominal surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic abdominal surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Intraperitoneal local anesthetics for postoperative pain management following intra-abdominal surgery: a systematic review and meta-analysis

IMPORTANCE

Although intraperitoneal local anesthetics are commonly used following intra-abdominal surgical procedures, the level of evidence supporting their use for postoperative pain management remains uncertain.

OBJECTIVE

To evaluate the effect of intraperitoneal local anesthetics on postoperative pain following intra-abdominal surgery.

DATA SOURCES

Medline (PubMed), Embase (Embase.com), CENTRAL, Web of science and ClinicalTrials.gov databases were searched from their inception to July 15th, 2022.

TRIAL SELECTION

Randomized controlled trials comparing IPLA to placebo, usual care or other analgesic regimens among patients of any age undergoing any type of surgery.

DATA EXTRACTION AND SYNTHESIS

Trial selection, data extraction, risk of bias assessment and the certainty of evidence were conducted in duplicate independently. Meta-analyses were performed using random effect models.

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were abdominal pain intensity at 6, 12, 24, 48, and 72 h after surgery. Secondary outcomes included postoperative nausea and vomiting, opioid use, recovery of gastrointestinal transit, length of hospital stay, postoperative chronic pain, persistent postoperative opioid use, quality of recovery and adverse events.

RESULTS

A total of 150 trials (n = 11,821 participants were included in our systematic review (97% of trials among adults). Intraperitoneal local anesthetics reduced postoperative pain intensity at 6 h (-0.86 point [95%CI -1.02 to -0.70]), 12 h (-0.74 point [95%CI -0.93 to -0.55]), 24 h (-0.65 point [95%CI -0.82 to -0.48]), and 48 h (-0.51 point [95%CI -0.70 to -0.31]), but not at 72 h (-0.38 point [95%CI -1.04 to 0.27]), with very low to low certainty of evidence. Modelled risk difference for achieving the clinically important effect and subgroup analyses among participants with moderate or high pain showed potential clinically significant effect from IPLA. Opioid use at 24 h (-10.4 mg of oral morphine equivalent [95% CI -13.1 to -7.6]), postoperative nausea and vomiting (RR 0.79 [95% CI -0.71 to 0.88]), and time to gastrointestinal transit recovery (-3.80 h [95% CI -7.54 to -0.07]) were also reduced. We found no association for other outcomes.

CONCLUSION AND RELEVANCE

Intraperitoneal local anesthetics may be associated with a small analgesic effect following intra-abdominal surgery. Considering the low to very low level of evidence supporting these findings, along with the limited data on adverse effects and long-term outcomes, their adoption as a standard of care intervention cannot be recommended at this stage.

REGISTRATION NUMBER

CRD42018115062.

Dosage of epidural morphine analgesia after lower abdominal cancer surgery: a randomized clinical trial among the older adults

BACKGROUND

Epidural morphine is considered one of the most potent drugs used for postoperative analgesia; however, its side effects are dose-related and exaggerated in elderly people. In this study, we aimed to determine which of three doses within that range (1.5 mg, 3 mg, or 4.5 mg) can provide adequate pain relief.

METHODS

A total of 102 patients were assessed for allocation into one of four groups to receive either placebo (group Morphine 0, N = 22), 1.5 mg of epidural morphine (Morphine 1.5, N = 22), 3 mg of epidural morphine (Morphine 3, N = 22), or 4.5 mg of epidural morphine (Morphine 4.5, N = 22) before skin incision, 24 h after surgery and 48 h after surgery. Cumulative intravenous IV-PCA morphine consumption, VAS pain scores, modified Ramsay Sedation Scores, nausea, vomiting, and pruritus were evaluated.

RESULTS

The VAS pain scores at activity of patients who received epidural morphine at doses of 3 mg and 4.5 mg were significantly lower than the placebo and 1.5 mg groups, VAS Score at 72 h was (2 ± 0.8) and (1.7 ± 1) vs (4.3 ± 1.1) and (4 ± 1) respectively, p value = 0.000. The mean total IV-PCA morphine consumption (mg) was significantly higher in patients who received received epidural 0.9% sodium chloride alone compared to 1.5 mg, 3 mg and 4.5 mg epidural morphine groups (38.1 ± 4.8 mg vs 27.2 ± 5.6 mg, 9.2 ± 3.5 mg, and 6.3 ± 3.3 mg respectively), p value = 0.000). However, the difference between the 3 mg and the 4.5 mg groups was not statistically significant in both of VAS scores and IV-PCA morphine consumption (P value > 0.05 for 3 mg vs. 4.5 mg). Patients who received 4.5 mg of epidural morphine experienced a significant increase in the level of sedation, measured by the Ramsay sedation scale, in comparison with 1.5 mg, 3 mg and placebo epidural morphine groups in the first 24 h, the Scale for this group was (2.5 ± 0.5) vs (2.1 ± 0.2, 2.1 ± 0.2, and 2.2 ± 0.5 respectively); p value = 0.000. No relationship between postoperative nausea and the dosage of epidural morphine was found.

CONCLUSION

Epidural morphine 3 mg as a bolus every 24 h with add on IV patient control analgesia (PCA) morphine, set to deliver 1.5 mg boluses on demand without background infusion with a lockout period of 45 min, could achieve effective and adequate analgesia lasting up to 72 h postoperatively without increasing in the level of sedation or other side effects in older adults after a lower abdominal cancer surgery.

Key updates in Crohn's disease surgery for the gastroenterologist in 2025

PURPOSE OF REVIEW

The field of inflammatory bowel disease (IBD) has been evolving at an unprecedented rate. Not only does this apply to the medical management of IBD but also to its surgical management. This review aims to highlight the major updates in the current surgical approach in Crohn's disease.

RECENT FINDINGS

Surgery for Crohn's disease is no longer considered only for medically refractory disease or for disease-related complications but can rather be considered as an effective first-line treatment option. The concept of multimodal prehabilitation is becoming more solidified in Crohn's disease, as strong evidence continues to indicate its positive impact on surgical outcomes. The impact of the mesentery as well as the type of surgical anastomosis on postsurgical Crohn's disease recurrence is being closely reexamined. The optimal approach for surgical management of perianal Crohn's disease is also being redefined.

SUMMARY

Surgery is an integral part of the care of Crohn's disease patients and keeping up with the evolving paradigm of surgery in Crohn's disease is critical for all providers taking care of Crohn's disease patients to ensure patients are getting the best care possible.

iColon, a patient-focused mobile application for perioperative care in colorectal surgery: Results from 444 patients

AimThe aim of this study is to assess if a patient-focused mobile application can increase compliance with active Enhanced Recovery After Surgery (ERAS) items and thereby improve surgery-related outcomes and patient satisfaction.MethodThis is a prospective observational study of patients admitted for elective colorectal surgery, under the ERAS protocol, and having access to the mobile application iColon during all perioperative phases.ResultsThe 444 participants were included in the study. The overall adherence to the use of iColon was 62.4%. The overall adherence to active ERAS items was 74.1%. Adherence to the use of iColon significantly impacted adherence to active ERAS items. The use of the application was negatively related with factors such as age, type of disease, and postoperative complications. In the postdischarge phase, low adherence to active ERAS items typically indicates an increased likelihood of readmission; however, the use of iColon correlated significantly with a reduction in the 30-day readmission rate. A survey regarding patient satisfaction and confidence in using iColon resulted in positive feedback in more than 94% of cases, while 92.7% reported better quality of care.ConclusionOur findings suggest that digital health tools are beneficial and effective in the follow up of patients after early discharge. Our mobile application, iColon, represents user-friendly technology that is well-accepted. It has real-world implications in increasing adherence to active ERAS items, which results in an improvement in perceived quality of care by its users.

A novel artificial intelligence framework to quantify the impact of clinical compared with nonclinical influences on postoperative length of stay

BACKGROUND

The relative proportion of clinical compared with nonclinical influences on length of stay after colectomy has never been measured. We developed a novel machine-learning framework that quantifies the proportion of length of stay after colectomy attributable to clinical factors and infers the overall impact of nonclinical influences.

STUDY DESIGN

Patients who underwent partial colectomy, total colectomy, or low anterior resection included in American College of Surgeons National Surgical Quality Improvement were analyzed. Multivariable linear regression, random forest, and neural network models were developed to assess the impact of 56 clinical variables on length of stay. The random forest and neural network models were fine-tuned to maximize the explanatory power of clinical variables on length of stay. R2 measured the proportion of length of stay explained by clinical factors. The contribution of nonclinical factors was inferred from residual analysis. Mean absolute error was used to measure the discrepancy between actual and model-predicted length of stay.

RESULTS

Of 96,081 patients, 71% underwent partial colectomy (mean length of stay, 6.8 days; standard deviation, 5.6), 27% low anterior resection (5.4; 4.4), and 2% total colectomy (11.8; 7.1). Clinical factors in multivariable linear regression models accounted for only 29-54% of length of stay variability. The random forest and neural network models demonstrated persistent unexplained length of stay variability even when considering nonlinear interactions (R2: random forest [range, 0.46-0.55]; neural network [range, 0.44-0.57]), consistent with multivariable linear regression models. Mean absolute error showed clinical factors could not account for 2-2.5 days of length of stay after low anterior resection and partial colectomy, and 4 days after total colectomy.

CONCLUSION

This is the first study to quantify the overall influence of clinical factors on post-colectomy length of stay, revealing they explain less than 55% of variability. By maximizing clinical factors' explanatory impact using machine learning, the remaining variability is inferred to be nonclinical. Our findings provide hospitals with a novel paradigm to indirectly measure the influence of previously elusive nonclinical factors.

Preoperative Antibiotic Compliance and Colorectal Surgical Site Infection in Children

INTRODUCTION

Surgical site infection (SSI) prevention "bundles" have been shown to reduce rates of SSI in adult colorectal surgery (CRS) patients. Our purpose was to investigate the association between selection and timing of preoperative antibiotics and incidence of SSI in pediatric CRS patients.

METHODS

We performed a retrospective analysis of a prospectively collected cohort study spanning January 2019-December 2022 comparing the incidence of SSI in all pediatric CRS patients at a single institution before and after implementation of a surgical "bundle" focused on appropriate selection and timely administration of prophylactic antibiotics. Antibiotic selection and timing were each categorized compliant or noncompliant. SSIs were stratified into superficial, deep incisional, and organ space infections. The primary outcome was incidence of SSI within 30 d of operation. Logistic regression analysis was performed.

RESULTS

Full compliance was noted in 56% of cases in the prebundle cohort and 88% of cases in the postbundle cohort. SSI rates were decreased by 44%. A logistic regression model failed to identify antibiotic selection or timing as an independent predictor of SSI.

CONCLUSIONS

The implementation of this perioperative surgical bundle was associated with a reduction in superficial SSI in pediatric CRS patients. Notably, specific adherence to antibiotic selection and timing of administration alone were not found to be predictive for reduction in SSI rates. These findings may support the use of surgical bundles in SSI reduction in pediatric patients undergoing CRS.

Postoperative anaemia is associated with poor long term postoperative outcomes after elective colorectal oncologic surgery within an enhanced recovery after surgery pathway

BACKGROUND

Anaemia is an independent risk factor for poor perioperative outcomes after major abdominal surgery, and is associated with an increased risk of 30-day postoperative mortality after noncardiac surgery.

OBJECTIVE

To investigate the frequency of postoperative anaemia and short- and long-term survival after colorectal oncologic surgery at a centre with a well-established Enhanced Recovery After Surgery (ERAS) program.

METHODS

We conducted a retrospective cohort study of all patients undergoing elective colorectal oncologic surgery within an ERAS pathway at our institution between 2013 and 2017. Overall survival was calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at hospital discharge.

RESULTS

A total of 680 patients were included. Patients with anaemia at discharge showed a lower overall survival at 5 years (53.9% vs. 44%, p 0.05). Patients who were anaemic at discharge had a lower 5-year overall survival (hazard ratio [HR] 95% CI 2.663 [1.619-4.379], p < 0.001). Kaplan-Meier survival and Cox regression proportional hazard survival for overall survival in the combined preoperative, postoperative, and RBC transfusion model were 1.55 (1.038 2.318) p = 0.032.

CONCLUSIONS

The combined prognostic value of preoperative anaemia, postoperative anaemia, and blood transfusion created a 40.7% higher risk of not surviving 5 years.

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

INTRODUCTION

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Fit4Surgery app: Home-based prehabilitation app for older patients undergoing elective colorectal cancer surgery

BACKGROUND

Supervised multimodal prehabilitation prior to colorectal cancer (CRC) surgery is associated with reduced complications and enhanced recovery. However, it is labor intensive and expensive. In an aging population with increasing demand and costs on healthcare and staff shortages, home-based prehabilitation (HBP) with an app could be of interest. This study assessed the effectiveness of a Fit4Surgery app in CRC surgery.

METHOD

The app was effectuated in a prospective cohort study of 100 CRC patients ≥60 years from October 2021-December 2022. The primary outcome was preservation or improvement of the 6-minute walking test (6MWT) six weeks postoperative, compared to baseline. Secondary outcomes were 90-day complication and mortality rate, 90-day readmission, length of stay, 6MWT and Short Performance Physical Battery (SPPB) at different timepoints and total costs.

RESULTS

Three patients needed urgent surgery, remaining 97 patients (mean age 72) using the app for at least three weeks. The 6MWT was preserved in 74.7 % with a 12.1 m higher mean six weeks postoperative, compared to baseline (p = 0.194). A significant higher 6MWT was observed after prehabilitation and one year postoperative, compared to baseline (p=<0.001). The SPPB was significant higher at all timepoints. Overall 90-day complication rate was 25.8 %, readmission rate 6.3 % and mortality occurred in 2.1 %. Total costs were €518.50 per patient.

CONCLUSION

This is the first study of multimodal HBP by an app for CRC surgery patients with high compliance. Results show promising results regarding functional capacity and a low occurrence of complications, in line with multimodal supervised prehabilitation. This by reducing costs by half.

Hospital resilience in the Face of Covid-19 in France: A multilevel analysis of the impact of past practice quality on cancer surgery resumption

The COVID-19 pandemic disrupted routine hospital services, causing a substantial backlog of surgeries in 2020. This study investigates hospital resilience in resuming activities during the pandemic, focusing on the impact of pre-pandemic adoption of enhanced recovery after surgery protocols (ERAS) in digestive cancer surgery. ERAS involves patient-centered care protocols proven to improve care process and outcomes but are not systematically implemented in hospitals. We define hospital resilience as the ability to maintain and resume surgery levels in the second half of 2020 during the pandemic. Using French national hospital data for digestive cancer surgeries, we categorized hospitals by the intensity of their ERAS volume before the pandemic and estimated a multilevel model allowing to control for hospital characteristics and pandemic conditions in the area they are situated. Results show that, all else being equal, hospitals that implemented ERAS before the pandemic absorbed the surgical backlog and recovered their pre-pandemic activity level more quickly. High-volume hospitals and specialized cancer centers were also quicker than other hospitals in resuming surgical operations. The findings highlight the differences in care practices across hospitals and the importance of quality protocols in bolstering hospital resilience during health crises. Beyond improving patient outcomes, widespread adoption of such protocols could enhance healthcare resource utilization and help to mitigate broader economic and environmental pressures.

Occurrence of an infectious complication may be a predictor of venous thromboembolism after surgery for colorectal cancer

Background

Venous thromboembolism (VTE) is a rare complication after colorectal cancer surgery, but may have a devastating outcome. The goal of this study was to report the incidence of VTE in our practice and identify predictors of VTE after colorectal resection for cancer.

Methods

This was a single-center retrospective cohort analysis. We used the hospital-specific Dutch Colorectal Audit database to identify patients that underwent oncologic colorectal resection between 2015 and 2022 and subsequently developed a VTE. Patients who used therapeutic anticoagulants postoperatively due to pre-existing conditions were excluded. During the study period, VTE prophylaxis was applied according to the local protocol. Patient characteristics and postoperative data were extracted from the patient records.

Results

Overall, 1261 patients were included, of which 13 patients developed VTE (1.0%). All cases involved pulmonary embolism. One patient (7.7%) had a simultaneous deep venous thrombosis. There were no deaths due to VTE. The incidence of other complications was significantly higher in patients with VTE (84.6% vs 28.5%; P ≤ .001). Multivariable logistic regression analysis indicated that the occurrence of an infectious complication was an independent predictor of VTE (odds ratio, 7.95; 95% CI, 2.20-28.69). Other variables that have previously been connected to the occurrence of VTE have been analyzed, but no other independent predictors were identified.

Conclusion

An infectious complication may be an independent predictor of the development of VTE. The necessity of prolonged prophylaxis after oncologic colorectal resections remains unclear.

Readmission and Adoption of Early Discharge After Colectomy Using ACS-NSQIP: Is It Time for Widespread Adoption?

INTRODUCTION

The timing of post-operative discharge following colectomy procedures remains a subject of debate among colorectal surgeons. Prior studies have demonstrated the safety and adoption of early discharge within 24 h after elective colectomy in carefully selected patients.

METHODS

This retrospective cohort study utilizing data from the American COllege of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2021. Adult patients undergoing elective partial colectomy with primary anastomosis and documented length of stay were included. Patients were stratified into early (< 24) and non early (≥24 h) discharge groups. Propensity score matching was used to control for baseline demographics and non-modifiable risk factors. Primary outcomes included 30-day readmission rates and adoption trends of early discharge over time.

RESULTS

A total of 282,037 patients met inclusion criteria of which 6364 (2.3%) were discharged within 24 h. On propensity score matching the early discharge cohort had a statistically significantly lower rate of readmission (5.5% versus 7.3%, P < 0.001). Additionally, the early discharge group had a significantly reduced rate of anastomotic leak (1.0 versus 2.6%), ileus (2.0% versus 7.6%), and rate of reoperation (1.2% versus 4.0%) (P < 0.001). The proportion of early discharge colectomies increased from 0.8% in 2012 to 3.6% in 2021 (P < 0.001).

CONCLUSIONS

In carefully selected patients, early discharge after colectomy with primary anastomosis does not increase the risk of readmission, reoperation, or 30-d complication rates. Furthermore, the increasing trend in utilization of early discharge after colectomy suggests an increasing acceptance of this practice, though it remains a minority of all colectomies performed among institutions participating in ACS-NSQIP.

Association of perioperative immunonutrition with anastomotic leak among patients undergoing elective colorectal surgery within a robust enhanced recovery after surgery program

BACKGROUND

Immunonutrition supplementation has been shown to reduce the risk of surgical infectious complications; however, its effect on decreasing anastomotic leak rates, in the context of an otherwise robust Enhanced Recovery After Surgery (ERAS) program, remains unclear. This study aims to assess the association between perioperative immunonutrition supplementation and anastomotic leak in an elective Enhanced Recovery After Surgery colorectal surgical population.

METHODS

We performed a retrospective single-institution cohort study consisting of adult patients enrolled in an Enhanced Recovery After Surgery pathway and undergoing elective colorectal surgery from 2018 to 2023. Immunonutrition supplementation was defined as a 10-day perioperative supply of commercially available nutritional shakes. Relevant demographic covariates, preoperative characteristics, and operative methods were identified and analyzed. Multivariable logistic regression was performed to determine the association of immunonutrition with anastomotic leak.

RESULTS

A total of 708 patients were included in the study, of which n = 400 (56.5%) received perioperative immunonutrition. Patients who received immunonutrition were more likely to be older (median age 57.9 vs 55.7), male (52.7% vs 44.8%), have a higher body mass index (27.7 vs 26.3), and less likely to be current smokers (9.8% vs 16.2%). On adjusted analysis, there was no association between immunonutrition use and anastomotic leak (odds ratio = 0.96, 95% confidence interval = 0.45, 2.08), 30-day readmission (odds ratio = 0.97, 95% confidence interval = 0.60, 1.57), or length of stay (β = .40, 95% confidence interval = -0.06, 0.86) CONCLUSION: We did not observe an association between perioperative immunonutrition supplementation and postoperative anastomotic leak, suggesting that the role of immunonutrition within a comprehensive Enhanced Recovery After Surgery program for elective colorectal surgery may warrant further evaluation.

Enhanced Recovery Independently Lowers Failure to Rescue After Colorectal Surgery

BACKGROUND

High adherence to the enhanced recovery after surgery pathway reduces morbidity and mortality rates after elective colorectal surgery.

OBJECTIVE

To evaluate the effect of adherence to the enhanced recovery after surgery pathway on the failure to rescue rates after elective colorectal surgery.

DESIGN

Retrospective analysis of a prospective database.

PATIENTS

Adults (18 years or older) who underwent elective colorectal resection with anastomosis for benign and malignant disease.

SETTINGS

Prospective enrollment in 78 centers in Italy from 2019 to 2021.

INTERVENTIONS

All outcomes were measured 60 days after surgery. Several patient-, disease-, treatment-, hospital-, and complication-related variables were analyzed. After univariate analyses, independent predictors of the end points were identified through logistic regression analyses, presenting ORs and 95% CIs.

MAIN OUTCOME MEASURES

Failure to rescue after any adverse event, defined as the ratio between the number of deaths and the number of patients showing any adverse event; failure to rescue after any major adverse event, with the denominator represented by the number of patients showing any major adverse event.

RESULTS

An adverse event was recorded in 2321 of 8359 patients (27.8%), a major adverse event in 523 patients (6.3%), and death in 88 patients (1.0%). The failure to rescue rates were 3.8% after any adverse event and 16.8% after any major adverse event. Independent predictors of primary end points were identified among patient- (age, ASA class, and nutritional status), treatment- (type of resection), and complication-related (anastomotic leakage and reoperation) variables. Enhanced recovery pathway adherence of more than 70% independently reduced failure to rescue rates.

LIMITATIONS

Clustering from multicenter data and unmeasured confounding from observational data.

CONCLUSIONS

After elective colorectal resection, adherence of more than 70% to the enhanced recovery pathway independently decreased failure to rescue rates, along with other patient- or treatment-related factors. See Video Abstract .

LA RECUPERACIN MEJORADA REDUCE DE FORMA INDEPENDIENTE LA POSIBILIDAD DE FRACASO EN EL RESCATE DESPUS DE UNA CIRUGA COLORRECTAL

ANTECEDENTES:La alta adherencia a la vía de recuperación mejorada después de la cirugía reduce las tasas de morbilidad y mortalidad después de la cirugía colorrectal electiva.OBJETIVO:Evaluar el efecto de la adherencia a la vía ERAS en las tasas de fracaso en el rescate después de la cirugía colorrectal electiva.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.PACIENTES:Adultos (≥ 18 años) que se sometieron a una resección colorrectal electiva con anastomosis por enfermedad benigna y maligna.ESCENARIO:Inscripción prospectiva en 78 centros en Italia de 2019 a 2021.INTERVENCIONES:Todos los resultados se midieron a los 60 días después de la cirugía. Se analizaron varias variables relacionadas con el paciente, la enfermedad, el tratamiento, el hospital y las complicaciones para los resultados. Después de los análisis univariados, se identificaron los predictores independientes de los puntos finales a través de análisis de regresión logística, presentando razones de probabilidades e intervalos de confianza del 95%.PRINCIPALES MEDIDAS DE RESULTADOS:Fallo en el rescate después de cualquier evento adverso, definido como la relación entre el número de muertes y el número de pacientes que presentaron cualquier evento adverso; fallo en el rescate después de cualquier evento adverso mayor, con el denominador representado por el número de pacientes que presentaron cualquier evento adverso mayor.RESULTADOS:Se registró un evento adverso en 2321 de 8359 pacientes (27,8%), un evento adverso mayor en 523 pacientes (6,3%) y muerte en 88 pacientes (1,0%). Las tasas de fallo en el rescate fueron del 3,8% después de cualquier evento adverso y del 16,8% después de cualquier evento adverso mayor. Se identificaron predictores independientes de los criterios de valoración primarios entre las variables relacionadas con el paciente (edad, clase de la Sociedad Americana de Anestesiólogos, estado nutricional), el tratamiento (tipo de resección) y las complicaciones (fuga anastomótica, reoperación). La adherencia a la vía de recuperación mejorada > 70% redujo de forma independiente las tasas de fallo en el rescate.LIMITACIONES:Agrupamiento de datos multicéntricos y factores de confusión no medidos a partir de datos observacionales.CONCLUSIONES:Después de una resección colorrectal electiva, la adherencia > 70 % a la vía de recuperación mejorada disminuyó de manera independiente las tasas de fracaso en el rescate, junto con otros factores relacionados con el paciente o el tratamiento. (Traducción-Dr Osvaldo Gauto).

Effect of neoadjuvant therapy on textbook outcomes in minimally invasive rectal cancer surgery

AIM

Textbook outcome (TO), a combined quality indicator, encompasses key postoperative indicators such as the absence of complications, R0 resection, and no prolonged length of day. It has been suggested to be of additional value over single outcome parameters in short-term outcomes of surgical treatment. The main objective of this research was to assess the relationship between TO and neoadjuvant therapy (NT), thereby providing insights into NT's role in surgical quality.

METHOD

Patients who underwent minimally invasive rectal surgery were enrolled between January 2019 and June 2024. TO was defined as achieving R0 resection, at least 12 lymph nodes harvested, no adverse outcomes (Clavien-Dindo score ≥ 3, readmission, or mortality within 30 days), and length of stay within the ≤ 75th percentile for the treatment year. The relationship between TO and NT was analyzed using regression analyses. Subgroup analysis and hierarchical regression were conducted to investigate potential influencing factors and interactions.

RESULTS

405 patients were enrolled, with 204 achieving TO. NT was associated with a reduction in TO (OR: 0.37, 95% CI: 0.21 ~ 0.65, p < 0.001), while robotic surgery (OR: 2.88, 95% CI: 1.62 ~ 5.11), total laparoscopic surgery (OR: 2.79, 95% CI: 1.71 ~ 4.56), enhanced recovery after surgery (OR: 1.62, 95% CI: 1.02 ~ 2.59), and stoma (OR: 1.87, 95% CI: 1.18 ~ 2.96) were associated with an increased rate of TO. The impact of NT on TO varied depending on surgery duration; prolonged surgical time exacerbated the negative effect of NT on TO. This observation was consistent with a significant interaction effect.

CONCLUSION

NT is associated with a lower TO rate, especially in patients with prolonged surgical time. Robotic surgery, total laparoscopic surgery, enhanced recovery after surgery, and stoma can improve achieve TO.

Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 3)-2025 update

Enhanced Recovery After Cesarean Delivery (ERAC) protocols include evidence-based interventions designed to improve maternal and neonatal outcomes and patient experiences while reducing healthcare-related costs. This is the first update to the Enhanced Recovery After Surgery Society guidelines for postoperative care in cesarean delivery published in 2019. Interventions were selected based on expert consensus. An updated literature search was performed in September 2024 using Embase, PubMed, MEDLINE, EBSCO CINAHL, Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2019 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each postoperative Enhanced Recovery After Cesarean Delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. After a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation system. The 13 recommended Enhanced Recovery After Cesarean Delivery interventions were (1) early drinking and feeding (low evidence, strong recommendation), (2) early discontinuation of intravenous fluid (very low evidence, strong recommendation), (3) early mobilization and ambulation (low evidence, strong recommendation), (4) early removal of urinary catheter (low evidence, strong recommendation), (5) scheduled acetaminophen (moderate evidence, strong recommendation), (6) scheduled nonsteroidal anti-inflammatory drugs (high evidence, strong recommendation), (7) oral rescue opioids (low evidence, strong recommendation), (8) standardized rescue medication protocol for side effects (low to moderate evidence, strong recommendation), (9) venous thromboembolism prophylaxis (low evidence, strong recommendation), (10) anemia remediation (moderate evidence, strong recommendation), (11) breastfeeding support and education (low evidence, strong recommendation), (12) promotion of rest periods (low evidence, strong recommendation), and (13) facilitate patient-centered transition to discharge (low evidence, strong recommendation). The 13 recommended postoperative interventions should be considered in the absence of contraindications in patients undergoing cesarean delivery to optimize maternal recovery and outcomes.

Efficacy of enhanced recovery programmes for cardiac surgery: a systematic review and meta-analysis

BACKGROUND

The terms fast-track (FT) and enhanced recovery after surgery (ERAS) are often mistakenly used interchangeably. Fast-track cardiac anaesthesia focuses on perioperative strategies, whereas ERAS (or enhanced recovery programme [ERP]) encompasses a wider range of strategies designed to enhance overall recovery. Evidence is needed to demonstrate the additive value of ERP above FT in cardiac surgery. We conducted a meta-analysis to investigate the comparative efficacy of ERP and FT programmes in cardiac surgery.

METHODS

We systematically searched PubMed, Embase, and Web of Science for randomised trials and prospective observational trials investigating ERP or FT programmes in cardiac surgery (up to November 16, 2024). Following PRISMA guidelines, two reviewers independently selected studies, extracted data, and assessed risk of bias. Data were pooled using a random-effects model. The primary efficacy outcome was hospital length of stay (LOS).

RESULTS

A total of 6368 articles were identified, of which 18 studies, with 2625 patients, were included. Compared with control, a significant reduction in hospital LOS (mean difference [95% confidence interval (CI)] -1.40 days [-2.19 to -0.61], P=0.001), ICU LOS (-13.22 h [-21.75 to -4.68], P=0.006), and ventilation time (-4.68 h [-7.85 to -1.52], P=0.008) was identified when ERP or FT programmes were implemented. ERP demonstrated an additive value above FT for hospital LOS (2.11 days [-3.52 to 0.71] vs -0.30 days [-0.88 to 0.27], respectively; P=0.003).

CONCLUSIONS

In cardiac surgery, ERP can reduce LOS in the ICU and hospital and ventilatory time. Moreover, it is suggested that ERPs, including preoperative, intraoperative, and postoperative interventions, are preferred above only intraoperative FT strategies.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42022382409).

Risk factors for unplanned 31-day readmission after surgery for colorectal cancer patients: a meta-analysis

BACKGROUND

The high incidence of unplanned readmissions within 31 days after colorectal cancer surgery remains a significant challenge. However, the identified risk factors for these readmissions are inconsistent across the literature. This study aims to perform a comprehensive meta-analysis to estimate the incidence of unplanned readmissions and systematically identify the factors associated with this risk, providing robust evidence for targeted interventions to reduce readmission rates.

METHODS

This study was conducted in accordance with the PRISMA guidelines. All study steps, including study selection, data extraction, and quality assessment, were independently performed by two authors, with any disagreements resolved through consultation with a third author. A comprehensive search for published studies was conducted across the following databases up to January 2025: VIP Journal Database, Wanfang Data, CNKI, SinoMed, PubMed, Embase, Web of Science, and the Cochrane Library. Statistical analyses were performed using RevMan 5.4 and Stata 17.0, with a p-value of less than 0.05 considered statistically significant.

RESULTS

This meta-analysis identified several significant risk factors associated with unplanned readmission during this period (P < 0.05), including age (OR = 1.13), postoperative complications (OR = 1.87), tumor stage (TNM ≥ III) (OR = 2.01), tumor site in the rectum (OR = 1.64), stoma creation (OR = 1.70), Complicated diabetes (OR = 1.56), Charlson Comorbidity Index (CCI) (OR = 1.27), blood transfusion (BT) (OR = 1.24), Length of hospital stay (LOS) (OR = 1.65), and surgical approach (OR = 1.22). Notably, female (OR = 0.85) was identified as a protective factor against unplanned readmission.

CONCLUSION

The unplanned readmission rate within 31 days after colorectal cancer surgery was 11.73%. Current evidence suggests that age, postoperative complications, TNM ≥ III, tumor site in the rectum, stoma creation, complicated diabetes, Charlson Comorbidity Index (CCI), blood transfusion (BT), length of hospital stay (LOS), and surgical approach are significant risk factors for unplanned readmission. Conversely, female has been identified as a protective factor. To mitigate these risks and reduce readmission rates, healthcare professionals should implement targeted educational and clinical interventions.

Introducing enhanced recovery after surgery (ERAS) program in Rwanda: a step-by-step approach from KAP study to protocol development and preliminary implementation

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs improve postoperative outcomes through evidence-based practices. However, implementing ERAS in resource-limited settings like Rwanda remains challenging. This study aimed to introduce an ERAS program at the Centre Hospitalier Universitaire de Kigali (CHUK) by tailoring it to the local context.

METHODS

A multi-phase strategy was employed, beginning with a Knowledge, Attitudes, and Practices (KAP) study following an ERAS webinar to identify gaps in awareness and application of ERAS principles among perioperative care providers. Targeted training sessions were conducted to address these gaps, leading to the development of a locally adapted ERAS protocol.

RESULTS

The KAP study revealed limited awareness of ERAS protocols, including international Nil Per Os (NPO) guidelines, with only 45.7% of participants familiar with them and 48% unknowingly applying some ERAS elements. Early postoperative feeding was supported by 45.7%, and 92.5% agreed that preventing nausea and vomiting enhances recovery. Regarding opioid use, 88.4% supported selective use, while 81.5% disagreed with eliminating opioids entirely. Almost all respondents (97.7%) believed ERAS improved perioperative care, and 79.2% felt it reduced hospital expenses. Additionally, 85% of respondents recognized laparoscopic surgery as enhancing ERAS protocols. The insights gained informed the design of targeted training sessions and the development of a locally adapted ERAS protocol, supported by the formation of collaborative groups and ERAS champions.

CONCLUSION

The introduction of ERAS at CHUK demonstrates the feasibility of implementing evidence-based surgical protocols in resource-limited settings. Addressing knowledge gaps and adapting protocols to the local context represent a promising step toward improving surgical care in Rwanda and enhancing perioperative management.

CLINICAL TRIAL NUMBER

Not applicable.

Robotic-assisted colorectal surgery in colorectal cancer management: a narrative review of clinical efficacy and multidisciplinary integration

Colorectal cancer (CRC) remains a formidable global health challenge, ranking among the most prevalent malignancies and a principal contributor to cancer-associated mortality. While traditional open surgery has historically been the cornerstone of CRC treatment, the advent of minimally invasive techniques, particularly robotic-assisted colorectal surgery (RACS), has garnered significant momentum owing to technological advancements in the field. Robotic platforms, exemplified by the da Vinci Surgical System, offer superior three-dimensional visualization, enhanced dexterity, and heightened precision, yielding improved perioperative outcomes, particularly in anatomically intricate regions such as the pelvis. This review provides a critical appraisal of the current landscape of RACS, emphasizing its superiority over conventional open and laparoscopic approaches. The increased control and precision afforded by robotic surgery have been shown to optimize outcomes in complex procedures such as total mesorectal excision, with evidence indicating reduced intraoperative blood loss, shortened hospital stays, and improved functional recovery. Nonetheless, challenges persist, including absence of haptic feedback, prohibitive costs, and steep learning curve associated with robotic systems. Despite these limitations, RACS has demonstrated considerable promise in sphincter-preserving and function-preserving procedures, ultimately enhancing postoperative quality of life. Beyond the surgical field, this review also investigates the integration of robotic surgery within multidisciplinary treatment strategies for CRC, particularly in the context of locally advanced rectal cancer. The combination of robotic techniques with total neoadjuvant therapy and immunotherapy-especially in tumors characterized by mismatch repair deficiency or high microsatellite instability has shown notable clinical efficacy. Furthermore, emerging personalized therapeutic approaches, including immunotherapies and targeted chemotherapeutic agents, emphasize the transformative potential of RACS in delivering superior oncologic outcomes. Looking towards the future, innovations in robotic platforms, including intraoperative imaging, artificial intelligence, and augmented reality, herald new possibilities for further enhancing the precision and efficacy of colorectal surgeries. The standardization of RACS protocols, alongside ongoing training and robust clinical research, will be critical to fully realizing the benefits of these advancements across diverse clinical settings. By incorporating cutting-edge technologies and personalized treatment methods, robotic-assisted surgery is prepared to become a cornerstone in future of CRC management, with the potential to significantly improve both survival outcomes and patient quality of life.

[Epidural anesthesia in thoracic and abdominal surgery : Current perspectives and practical implications]

With the rise of minimally invasive and robot-assisted surgical techniques, the role of epidural anesthesia (EA) in modern practice necessitates careful re-evaluation. This review explores the relevance of EA in thoracic and abdominal surgery, examining its practical applications, residual indications and considerations for its use. Additionally, alternative pain management strategies, including systemic analgesia, regional nerve blocks and novel perioperative approaches, are assessed for advantages and limitations compared to EA.Traditionally the gold standard for perioperative pain control in thoracic and abdominal procedures, EA provides superior analgesia, reduced pulmonary complications and promotes early postoperative mobilization; however, the shift towards less invasive types of surgery has raised questions about the necessity and risk-benefit profile of EA. Complications such as hypotension, hematoma and rare neurological injuries emphasize the importance of thorough risk assessment.Emerging data show that alternative methods, such as transversus abdominis plane (TAP) blocks, paravertebral blocks and multimodal analgesia provide comparable efficacy in specific patient groups while often demonstrating a better safety profile. Nevertheless, EA remains essential in extensive thoracic surgery, complex abdominal resections and in patients with a high risk for severe postoperative pain or respiratory compromise. Combining EA with enhanced recovery after surgery (ERAS) protocols has also shown promise in improving outcomes.In conclusion, while minimally invasive surgical techniques have transformed perioperative care, EA retains a critical role in selected indications. Individualized planning of anesthesia, weighing EA against evolving alternatives and tailored to surgical and patient-specific factors, is essential. This review highlights the integration of evidence-based strategies to optimize the role of EA in contemporary surgical treatment.

A multimodal prehabilitation class for Enhanced Recovery After Surgery: a pragmatic randomised type 1 hybrid effectiveness-implementation trial

BACKGROUND

Prehabilitation promotes postoperative recovery through preoperative optimisation; however, few studies have been conducted under real-world conditions. Our objective was to determine the extent to which a multimodal prehabilitation programme influenced intermediate and late recovery post-colorectal surgery in a type 1 effectiveness-implementation and randomised pragmatic trial. We hypothesised that a prehabilitation class, as part of an Enhanced Recovery After Surgery (ERAS) pathway, would reduce length of hospital stay (LOS).

METHODS

Adult male and female patients with colorectal disease requiring an elective primary resection at a single centre were randomised to the intervention or standard care group at least 2 weeks before surgery. All participants attended an ERAS class, which was extended to include prehabilitation components of nutrition education, supplements, walking with a smartwatch, functional exercises, and deep breathing in the intervention group. Effectiveness outcomes included LOS (primary) and 6-min walking distance (6MWD; secondary outcome) at 6 weeks post-surgery. Implementation outcomes included adherence to prescribed step count and nutrient intakes. Multivariable regression analyses were adjusted for age, sex, type of surgery, and COVID-19.

RESULTS

The study ended prematurely. In total, 110 patients were included. Two-thirds had cancer and mean prehabilitation duration was 17.2 (sd 5.5) days. LOS was not different between groups. Preoperative median step count did not differ between groups, but protein inadequacy (prevalence ratio: 0.59 [95% CI: 0.36-0.82]) decreased substantially with prehabilitation. After surgery, the mean difference in 6MWD was +38 m (95% CI: 9-67 m) for prehabilitation vs control, indicating earlier functional recovery.

CONCLUSIONS

A pragmatic prehabilitation programme did not influence length of hospital stay (underpowered because of early trial termination), but did reduce preoperative protein inadequacy (implementation outcome) and improve early functional recovery (secondary outcome).

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT04247776).

Variation in perioperative practice in elective colorectal cancer surgery: opportunities for quality improvement

BACKGROUND

Understanding the variation in perioperative care across a population is fundamental to improving the management and outcomes of patients with colorectal cancer. Currently, there is limited individual patient level data available to assess this variation. Therefore, as part of an improvement programme, we conducted an audit to understand perioperative care.

METHODS

Audit items were developed to cover the pre, intra and postoperative phases of the colorectal cancer surgical pathway and collected for patients undergoing an elective procedure. The audit was conducted at 14 Hospital Trusts, participating in the Yorkshire Cancer Research Bowel Cancer Improvement Programme, located in the Yorkshire and Humber region, North of England.

RESULTS

Information on 216 patients were collected. Functional assessment by Cardiopulmonary Exercise Testing varied across the region (performed in 100% patients at three Trusts, but not at all in six Trusts, P < 0.001). The provision of postoperative high dependency and critical care also varied across the region (in seven Trusts ≥ 80% of patients went to a monitored bed or higher level of care; in three Trusts ≥ 90% of patients received ward care, P < 0.001). The median duration of preoperative starvation varied by Trust (2 to 13 h, P < 0.001). The intraoperative dose of opiate administered to patients varied significantly between Trusts (P < 0.001).

CONCLUSIONS

There is wide variation in both the provision and practice of perioperative care across a large region in the North of England. The findings are informing a programme of improvement science-based work to improve the management and outcomes of patients with colorectal cancer.

Effect of enhanced surgical recovery program for thoracolumbar spine surgery on opioid use, length of hospital stay, and hospital readmissions: evaluation of 51,236 cases

BACKGROUND CONTEXT

Evidence-based enhanced surgical recovery (ESR) programs integrate a multidimensional approach to optimize patients during the pre-, intra-, and postoperative phases of surgery. Smaller studies suggest several benefits of spine surgery ESR; this study evaluates the effects of ESR for thoracolumbar (TL) fusion surgery on a national scale.

PURPOSE

Determine if ESR is associated with a reduction in daily morphine milligram equivalents (MME), length of hospital stay (LOS), and 30-day readmission (READMIT) rates compared to non-ESR controls.

STUDY DESIGN

Multicenter, retrospective, case-control study of a prospectively adopted healthcare system ESR program from October 2018 to December 2021.

PATIENT SAMPLE

Consecutive adult patients undergoing TL fusion with known ESR participation status and without a primary diagnosis of tumor, infection, or trauma were included.

OUTCOMES MEASURES

Primary outcomes include daily MME, LOS, and 30-day READMIT rates. Outcomes were analyzed for single-level, multi-level, and all TL fusions.

METHODS

Data from TL fusion procedures performed within a large healthcare system were extracted from hospital-based electronic medical records derived from 1352 surgeons within 138 facilities. Patients were divided as ESR (cases) or non-ESR (controls) based upon enrollment into an ESR program defined by (1) preoperative patient education, (2) multimodal analgesia, (3) intraoperative fluid optimization, (4) opioid-sparing anesthesia, and (5) early postoperative nutrition and ambulation. Outcomes were compared between groups.

RESULTS

Of 51,236 TL fusion cases (45% male, mean age of 63 years), 24,391 participated in an ESR program and 26,845 did not. For single-level TL fusions, ESR was associated with decreased MME (β= -8.76, p<.001), LOS (β= -8.85, p<.001), and READMIT (OR=0.77, 95% CI: 0.67-0.88) compared to controls. For multi-level TL fusions, ESR was associated with decreased MME (β= -7.32, p<.001) and LOS (β= -12.14, p<.001) compared to controls. For all TL fusions, ESR was associated with decreased MME (β= -7.94, p<.001), LOS (β= -10.54, p<.001), and READMIT (OR=0.91, 95% CI: 0.84-0.98) compared to non-ESR controls.

CONCLUSIONS

This national healthcare system analysis of over 50,000 TL spine fusion cases by 1,352 surgeons at 138 centers across the US confirms that ESR adoption is associated with decreased daily MME, LOS, and READMIT compared to non-ESR controls. Surgeons should consider adoption of ESR programs to improve patient care.

Early detection and correction of preoperative anemia in patients undergoing colorectal surgery-a prospective study

INTRODUCTION

Preoperative anemia is an important target in preventing colorectal anastomotic leakage (CAL). However, it is not consistently detected and corrected in patients undergoing colorectal surgery. This study aimed to evaluate the impact of early detection and correction of preoperative anemia on perioperative outcomes and CAL.

METHODS

This was a prospective subanalysis of an international open-labeled trial, which implemented an enhanced care bundle to prevent CAL after elective colorectal surgeries. It introduced interventions for early detection and correction of preoperative anemia. Primary outcome was the incidence of preoperative anemia and the effect of early correction. Secondary outcomes included the impact on CAL, postoperative course, and mortality.

RESULTS

The study included 899 patients across eight European hospitals (September 2021-December 2023). Preoperative anemia was identified in 35.0% (n = 315) of participants, with 77.4% (n = 192) receiving iron therapy. Hemoglobin levels decreased in 4.2% (n = 13), remained stable in 45.8% (n = 143), and increased in 50.0% (n = 156) (p < 0.001). Perioperative hyperglycemia was more common among patients with anemia (7.8% versus 16.4%, p < 0.001). CAL occurred in 6.1% (n = 53) of patients. Anemia correction and changes in hemoglobin levels after iron treatment were not significantly associated with CAL, other complications, or mortality.

CONCLUSIONS

Early detection and correction of preoperative anemia is achievable. However, routine preoperative administration of iron alone, without concurrently optimizing other CAL risk factors, does not result in CAL prevention. Preoperative anemia indicates overall poor physiological fitness rather than being an isolated risk factor.

TRIAL NUMBER

NCT05250882 (20-01-2022).

The Effects of Early Oral Intake in the Postanesthesia Care Unit on Nausea and Vomiting: A Meta-analysis of Randomized Controlled Trials

PURPOSE

This systematic review and meta-analysis aimed to investigate whether early oral fluid intake after surgery compared with delayed oral intake causes nausea and vomiting in pediatric patients who underwent general anesthesia in the postanesthesia care unit (PACU).

DESIGN

Systematic review and meta-analysis.

METHODS

Conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (version 6.4), this study searched electronic databases, including Pubmed, CINAHL, Embase, Cochrane CENTRAL, PubMed, RISS, and KoreaMed up to July 2023. The Risk of Bias 2 tool assessed the risk of bias, and R statistical software facilitated meta-analysis. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

FINDINGS

A meta-analysis of 6 randomized controlled trials (RCTs) (2,723 patients) found early oral intake in the PACU decreased vomiting incidence by 36% compared with delayed oral fluid intake (risk ratio = 0.64, 95% confidence interval: 0.42 to 0.97, P = .040, I2 = 7%) with moderate certainty of evidence. Another meta-analysis of 3 RCTs (2,185 participants) showed that early oral intake did not increase nausea compared with delayed oral intake (95% confidence interval: -0.76 to 0.07, P = .071, I2 = 0%) with low certainty of evidence.

CONCLUSIONS

Early oral fluid intake in the PACU decreases postoperative vomiting without raising nausea. Health care providers should consider implementing early oral fluid intake in the PACU for enhanced recovery of pediatric patients.

Transversus Abdominis Plane Block vs. Wound Infiltration for the Reduction of Postoperative Patient-Controlled Analgesia Requirements Following Laparoscopic Hemicolectomy: A Retrospective Case-Control Study

Introduction Transversus abdominis plane (TAP) blocks and wound infiltration are commonly used regional analgesic techniques in laparoscopic colorectal surgery. However, their comparative efficacy remains uncertain. This study aimed to evaluate whether TAP blocks reduce postoperative morphine consumption and patient-controlled analgesia (PCA) duration compared to wound infiltration following laparoscopic hemicolectomy. Methods We conducted a retrospective case-control study comparing postoperative opioid requirements and PCA duration in patients who received TAP blocks versus wound infiltration for laparoscopic hemicolectomy. Landmark vs ultrasound-guided TAP block techniques were also compared. The primary outcome was total postoperative morphine consumption via PCA, and the secondary outcome was PCA duration. Data on postoperative adjunct analgesia and patient demographics were also collected. Results Comparing TAP blocks (n=59) and wound infiltration (n=33), no significant difference was found between groups in postoperative morphine consumption via PCA (p=0.111), PCA duration (p=0.092), or average daily morphine requirement via PCA (p=0.452). Comparing ultrasound-guided (n=21) and landmark (n=38) TAP block techniques also yielded no significant difference between groups for each of these dependent variables. Variability in opioid use was high, with large standard deviations observed in all groups. Discussion TAP blocks did not demonstrate a significant opioid-sparing effect compared to wound infiltration following laparoscopic hemicolectomy. These findings contribute to a growing body of literature with conflicting evidence on the efficacy of TAP blocks. However, TAP blocks may offer benefits beyond postoperative opioid-sparing effects. Further prospective studies incorporating postoperative pain scores and recovery metrics are needed to determine their clinical utility in multimodal analgesia protocols for colorectal surgery.

Preoperative posterior quadratus lumborum block: determining the minimum effective ropivacaine concentration in 90% of patients (MEC90) for postoperative analgesia after laparoscopic myomectomy

BACKGROUND

Quadratus lumborum block (QLB) has gained traction as a regional anesthesia technique to manage postoperative pain following laparoscopic surgery. However, the 90% minimum effective concentration (MEC90) of local anesthetics for posterior QLB remains undetermined.

METHODS

We conducted a double-blind, comparative dose-finding study involving 54 women scheduled for elective laparoscopic myomectomy under general anesthesia. Each patient received a bilateral posterior QLB with 20 mL of ropivacaine on each side. The concentration administered varied for each patient and was determined based on the response of the previous participant. The initial concentration was set at 0.20%. Upon successful block, the subsequent patient was assigned to receive either the same (probability of 0.89) or a 0.05% lower concentration (probability of 0.11). In cases of block failure, the concentration was increased by 0.05% for the next patient. The trial concluded when 45 successful blocks were achieved, with block success defined as a pain score of three or fewer 30 minutes after arrival in the post-anesthesia care unit.

RESULTS

The 90% minimum effective concentration (MEC90) of ropivacaine was 0.340% (95% CI 0.329 to 0.344%).

CONCLUSIONS

The optimal concentration of ropivacaine for posterior QLB to achieve satisfactory analgesia following laparoscopic myomectomy is a 20 mL volume of 0.340% ropivacaine per side.

REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200055743.

Enhanced recovery after surgery (ERAS) in stoma reversal surgery: a systematic review and meta-analysis

Stoma reversal surgery is known for relatively high complication rates. While Enhanced Recovery After Surgery (ERAS) protocols are extensively validated for colorectal surgery, their use in stoma reversal remains underexplored. This systematic review and meta-analysis evaluates clinical outcomes of stoma reversal surgery under ERAS protocols compared to standard care (SC) practices. Medline, EMBASE, and Cochrane Central databases were searched for studies that compared clinical outcomes of stoma reversal surgery under ERAS protocols versus SC practices. The endpoints of interest were length of stay (LOS), ileus, wound infection, anastomotic leak, time to first stool, overall, minor, and major postoperative complications, readmission rates, and reoperation rates. Mean difference (MD) was calculated for continuous variables and Odds Ratio (OR) for dichotomous variables. Statistical analysis was performed with R version 4.4.0. We included eight studies comprising 1322 patients. Among these, 603 (45.6%) followed an ERAS protocol, while 719 (54.4%) received SC practices. ERAS was associated with a significant decrease in LOS (MD -1.83; 95% CI -2.55 to -1.12; p < 0.01), wound infection (OR 0.47; 95% CI 0.23 to 0.97; p = 0.041), and time to first stool (MD -1.02; 95% CI -1.22 to -0.81; p < 0.01). No statistically significant difference was observed regarding ileus, anastomotic leak, overall, minor, and major postoperative complications, readmission rates, or reoperation rates. The implementation of ERAS protocols in stoma reversal procedures should be considered, as it was associated with a shorter length of hospital stay without increasing morbidity, and may even reduce complications such as wound infections.

Exploring the experiences of patients who receive nutrition education for ostomy care: A qualitative research design

BACKGROUND

Ileostomy and colostomy patients benefit from more nutrition education than patients who receive bowel resections without ostomy creation. Nutrition can influence the adaptation to a stoma and may help manage complications. The impact of nutrition education on health outcomes is known, but a gap exists for the type and timing of nutrition information for patients with newly formed ostomies.

METHODS

A survey of open-ended and closed-ended questions was designed to evaluate experiences about nutrition education provided for living with an ostomy. The survey was conducted during hospital admission for ostomy reversal: 39 patients were approached, 36 consented, and all 36 completed the survey.

RESULTS

Of the 36 patients who took part in the study, 20 (56%) were male. The mean age was 57.7 years. Twenty-four (67%) patients were admitted for an ileostomy reversal and 12 (33%) patients for a colostomy reversal. When patients were asked about their preferred timing of nutrition education, 28% (n = 10) wanted information before surgery, 58% (n = 21) wanted the information in the hospital when admitted for ostomy creation, and 14% (n = 5) wanted to receive it after discharge. A total of 25% (n = 9) of patients commented on the need for a follow-up phone call after discharge to ask questions.

CONCLUSION

Nutrition education is valuable for patients, and most patients want to receive nutrition information while in the hospital. A follow-up session with a dietitian after discharge could assist patients in developing strategies to manage weight changes, prevent dehydration, and lower the risk of malnutrition.

The Effect of Prolonged Fasting Before Surgery on Pain and Anxiety

PURPOSE

To investigate the effect of prolonged fasting before surgery on pain and anxiety.

DESIGN

This was a descriptive study.

METHODS

This study was conducted in a plastic, reconstructive, and esthetic surgery clinic at a university hospital in Bursa, Turkey. A data collection tool was designed to collect data on the sociodemographic characteristics. The Beck Anxiety Scale was used to assess patients' anxiety in the preoperative period and the Visual Analog Scale was used to measure pain levels in the postoperative period. The Statistical Package for Social Sciences was used for data analysis.

FINDINGS

A total of 363 patients took part in the study. A majority (91.2%) of the patients who participated in the study were aware of why they were fasting before surgery, and 41.6% of them had been informed about preoperative fasting by the nurse. In addition, 60.9% of patients had thirst, 17.6% had headache, 40.5% were hungry, 62% had dry mouth, 79.6% were restless, and 83.7% were anxious. Most (82.6%) of the patients who participated in the study had a preoperative fasting period of more than 6 hours, 58.4% had a postoperative fasting period of 5 hours or less, and the mean fasting period was 6.82 ± 1.76. The mean score of the Visual Comparison Scale was 5.09 ± 0.31 and the mean score of the Beck Anxiety Scale was 21.86 ± 0.054, and patients with a fasting period of 6 hours or more experienced more pain and anxiety.

CONCLUSIONS

This study shows that patients with longer fasting duration experience more pain and anxiety, and patients with more anxiety experience more pain. Based on the results of this study, it is recommended that studies should be done to emphasize the issue and to increase the awareness of health care professionals about pre- and postoperative fasting.

Narrative review: nutritional strategies for ageing populations - focusing on dysphagia and geriatric nutritional needs

The increase in elderly populations worldwide highlights the urgency of addressing age-related problems through effective nutritional management to enhance the well-being of the elderly and for the prevention and treatment of various diseases. The trend towards an increasing elderly population brings with it an increase in conditions such as sarcopenia, osteosarcopenia and frailty, emphasising the importance of regular checks for malnutrition in the elderly and the implementation of personalised nutritional therapies. The importance of nutrition in addressing geriatric syndromes such as frailty, sarcopenia, osteosarcopenia, obesity and metabolic syndrome is highlighted. Dysphagia, frequent in the elderly, requires special attention to prevent malnutrition and complications. It is essential to maintain muscle mass and bone health in old age. In this review we investigate the fundamental role of nutrition in geriatrics, focusing on promoting healthy ageing and managing problems such as malnutrition and overeating. The importance of protein intake and healthy dietary patterns such as the Mediterranean diet are then discussed. Finally, the challenges of personalised nutritional care, including the need for artificial nutrition or oral supplements, to improve quality of life and health care in an ageing society are addressed.

Intraoperative Methadone: A New Enhanced Recovery After Surgery Pathway for Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. Previous studies have shown that just one dose of methadone can achieve better analgesia than multiple doses of short-acting opioids. This study aims to evaluate the effectiveness of our Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator flap breast reconstruction centered around a single weight-based intraoperative dose of methadone.

METHODS

The authors retrospectively reviewed patients from October 2020 to March 2021 to establish a historical control cohort (n = 29). The ERAS protocol was implemented in April 2021, and patients were prospectively enrolled in the ERAS cohort from April 2021 to January 2022 (n = 54). Primary outcomes compared between the ERAS and historical cohorts using univariate analysis were length of stay, postoperative opioid consumption, pain scores, heart rates, and incidence of tachycardia.

RESULTS

There was no difference in the length of stay between our ERAS and non-ERAS cohorts (P = 0.68). Patients in the ERAS pathway had significantly less opioid consumption at 12 hours postoperatively (P < 0.001), 24 hours postoperatively (P < 0.001), and throughout the entire admission (P = 0.002). Pain scores were significantly lower in the ERAS cohort at 24 hours postoperatively (P = 0.021) and throughout admission (P = 0.0051). The ERAS cohort had significantly lower heart rates at 12 hours postoperatively (P = 0.0014), 24 hours postoperatively (P < 0.001), and throughout admission (P < 0.001). The incidence of tachycardia was also significantly lower in the ERAS cohort (P = 0.029).

CONCLUSIONS

This preliminary data after newly instituting our ERAS protocol with a single dose of intraoperative methadone significantly reduced postoperative opioid analgesic usage, pain scores, heart rates, and incidence of tachycardia. This pilot study demonstrates that methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease postoperative pain, opioid use, and increase overall patient comfort and satisfaction.

Rise in Minimally Invasive Surgery for Colorectal Cancer Is Associated With Adoption of Robotic Surgery

BACKGROUND

Minimally invasive surgery is associated with improved short-term outcomes and similar long-term oncologic outcomes for patients with colorectal cancer compared with open surgery. Although the robotic approach has ergonomic and technical benefits, how it has impacted the utilization of traditional laparoscopic surgery and minimally invasive surgery overall is unclear.

OBJECTIVE

Describe trends in open, robotic, and laparoscopic approaches for colorectal cancer resections and examine factors associated with minimally invasive surgery.

DESIGN

Retrospective cohort study using data from the National Cancer Database from 2010 to 2020.

SETTING

Commission on Cancer-accredited US facilities.

PATIENTS

Patients diagnosed with nonmetastatic colon or rectal adenocarcinoma.

MAIN OUTCOME MEASURES

Surgical approach rates (open, robotic, and laparoscopic).

RESULTS

We identified 475,001 patients diagnosed with nonmetastatic colorectal adenocarcinoma, of whom 192,237 (40.5%) underwent open surgery, 64,945 (13.7%) underwent robotic surgery, and 217,819 (45.9%) underwent laparoscopic surgery. For colon cancer, laparoscopic minimally invasive surgery use steadily increased, with a peak prevalence of 54.0% in 2016, and total minimally invasive surgery (robotic + laparoscopic) was performed more often than open surgery from 2013 through 2020. For rectal cancer, laparoscopic minimally invasive surgery had a peak prevalence of 37.2% in 2014 and declined from 2014 through 2020; robotic surgery prevalence increased throughout the study period (5.5% in 2010, 24.7% in 2015, and 48.8% in 2020). Minimally invasive surgery use increased in facilities performing robotic surgery every year during the study period. For both colon and rectal cancer, the use of open surgery decreased across all facilities throughout the study period.

LIMITATIONS

This study used the National Cancer Database, which may not be generalizable to non-Commission on Cancer institutions.

CONCLUSIONS

Minimally invasive surgery steadily increased across all facilities from 2010 through 2020. Open resections declined, laparoscopic resections plateaued, and robotic resections increased for colon and rectal cancer. Minimally invasive surgery increases may be driven by increases in robot-assisted surgery. See Video Abstract.

EL AUMENTO DE LA CIRUGA MNIMAMENTE INVASIVA PARA EL CNCER COLORRECTAL SE ASOCIA CON LA ADOPCIN A LA CIRUGA ROBTICA

ANTECEDENTES:La cirugía mínimamente invasiva se asocia con mejores resultados a corto plazo y resultados oncológicos similares a largo plazo para pacientes con cáncer colorrectal en comparación con la cirugía abierta. Aunque el abordaje robótico tiene beneficios ergonómicos y técnicos, no está claro cómo ha afectado la utilización de la cirugía laparoscópica tradicional y la cirugía mínimamente invasiva en general.OBJETIVO:Describir las tendencias en los abordajes abiertos, robóticos y laparoscópicos para las resecciones de cáncer colorrectal y examinar los factores asociados con la cirugía mínimamente invasiva.DISEÑO:Estudio de cohorte retrospectivo utilizando datos de la Base de Datos Nacional del Cáncer desde 2010 hasta 2020.ESCENARIO:Centros estadounidenses acreditados por la Comisión sobre el Cáncer.PACIENTES:Pacientes diagnosticados con adenocarcinoma de colon o recto no metastásico.PRINCIPALES MEDIDAS DE VALORACIÓN:Tasas de abordaje quirúrgico (abierto, robótico, laparoscópico).RESULTADOS:Identificamos 475.001 pacientes con diagnóstico de adenocarcinoma colorrectal no metastásico, de los cuales 192.237 (40,5%) se sometieron a cirugía abierta, 64.945 (13,7%) se sometieron a cirugía robótica y 217.819 (45,9%) se sometieron a cirugía laparoscópica. Para el cáncer de colon, el uso de cirugía mínimamente invasiva laparoscópica aumentó de manera constante, con una prevalencia máxima del 54,0% en 2016, y la cirugía mínimamente invasiva total (robótica + laparoscópica) se realizó con mayor frecuencia que la cirugía abierta desde 2013 hasta 2020. Para el cáncer de recto, la cirugía mínimamente invasiva laparoscópica tuvo una prevalencia máxima del 37,2% en 2014 y disminuyó desde 2014 hasta 2020; La prevalencia de la cirugía robótica aumentó durante el período de estudio (5,5 % en 2010, 24,7 % en 2015, 48,8 % en 2020). El uso de cirugía mínimamente invasiva aumentó en los centros que realizan cirugía robótica cada año durante el período de estudio. Tanto para el cáncer de colon como para el cáncer de recto, el uso de cirugía abierta disminuyó en todos los centros durante el período de estudio.LIMITACIONES:Se utilizó la base de datos nacional sobre el cáncer, que puede no ser generalizable a instituciones que no pertenecen a la Comisión sobre el Cáncer.CONCLUSIONES:La cirugía mínimamente invasiva aumentó de manera constante en todos los centros entre 2010 y 2020. Las resecciones abiertas disminuyeron, las resecciones laparoscópicas se estabilizaron y las resecciones robóticas aumentaron para el cáncer de colon y recto. Los aumentos de la cirugía mínimamente invasiva pueden estar impulsados por aumentos en la cirugía asistida por robot. (Traducción--Ingrid Melo ).