Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay

Trends in the adoption of diverting loop ileostomy for acute complicated diverticulitis in the United States

BACKGROUND

Acute complicated diverticulitis poses a substantial burden to individual patients and the health care system. A significant proportion of the cases necessitate emergency operations. The choice between Hartmann's procedure and primary anastomosis with diverting loop ileostomy remains controversial.

METHODS

Using American College of Surgeons National Surgical Quality Improvement Program patient user file data from 2012 to 2020, patients undergoing Hartmann's procedure and primary anastomosis with diverting loop ileostomy for nonelective sigmoidectomy for complicated diverticulitis were identified. Major adverse events, 30-day mortality, perioperative complications, operative duration, reoperation, and 30-day readmissions were assessed.

RESULTS

Of 16,921 cases, 6.3% underwent primary anastomosis with diverting loop ileostomy, showing a rising trend from 5.3% in 2012 to 8.4% in 2020. Primary anastomosis with diverting loop ileostomy patients, compared to Hartmann's procedure, had similar demographics and fewer severe comorbidities. Primary anastomosis with diverting loop ileostomy exhibited lower rates of major adverse events (24.6% vs 29.3%, P = .001). After risk adjustment, primary anastomosis with diverting loop ileostomy had similar risks of major adverse events and 30-day mortality compared to Hartmann's procedure. While having lower odds of respiratory (adjusted odds ratio 0.61, 95% confidence interval 0.45-0.83) and infectious (adjusted odds ratio 0.78, 95% confidence interval 0.66-0.93) complications, primary anastomosis with diverting loop ileostomy was associated with a 36-minute increment in operative duration and increased odds of 30-day readmission (adjusted odds ratio 1.30, 95% confidence interval 1.07-1.57) compared to Hartmann's procedure.

CONCLUSION

Primary anastomosis with diverting loop ileostomy displayed comparable odds of major adverse events compared to Hartmann's procedure in acute complicated diverticulitis while mitigating infectious and respiratory complication risks. However, primary anastomosis with diverting loop ileostomy was associated with longer operative times and greater odds of 30-day readmission. Evolving guidelines and increasing primary anastomosis with diverting loop ileostomy use suggest a shift favoring primary anastomosis, especially in complicated diverticulitis. Future investigation of disparities in surgical approaches and patient outcomes is warranted to optimize acute diverticulitis care pathways.

Phase 1 randomized trial of inpatient high-intensity interval training after major surgery

BACKGROUND

High-intensity interval training (HIT) can provide physiologic benefits and may improve postoperative recovery but has not been evaluated in inpatients. This study aimed to evaluate the safety and tolerability of HIT after major surgery.

METHODS

We performed a phase I randomized study comparing HIT with low-intensity continuous ambulation (40 m) during the initial inpatient stay after major surgery at a large academic center. Clinicopathologic and pre- and post-exercise physiologic data were captured. Perceived exertion was measured throughout the intervention.

RESULTS

Twenty-two subjects were enrolled and randomized with 90% (20 subjects, 10 per arm) completing all aspects of the study. One patient declined participation in the exercise intervention. The HIT and continuous ambulation groups were relatively similar in terms of median age (65.5 vs 63.5), female sex (20% vs 40%), White race (90% vs 90%), having a cancer diagnosis (100% vs 80%), undergoing gastrointestinal surgery (60% vs 80%), median Karnofsky score (60 vs 60), and ability to independently ambulate preoperatively (100% vs 90%). All subjects completed the exercise without protocol deviation, cohort crossover, or safety events. Compared with the continuous ambulation group, the HIT group had higher end median perceived exertion (5.0 [IQR, 5.5] vs 3.0 [IQR, 1.8]), shorter overall time to complete assigned exercise (56.6 seconds vs 91.8 seconds), and a trend toward higher median gait speed over 40 m (0.71 m/s vs 0.44 m/s, P = .126).

CONCLUSION

HIT in the hospitalized postoperative patient is safe and may be implemented to help promote positive physiologic outcomes and recovery.

Enhanced recovery after surgery (ERAS) in colorectal surgery: implementation is still beneficial despite modern surgical and anesthetic care

PURPOSE

Enhanced recovery after surgery (ERAS) protocols have shown beneficial outcomes in the last 20 years. Nevertheless, simultaneously implemented technical improvements such as minimally invasive access or modified anesthesia care may play a crucial role in optimizing patient outcome. The aim of the study was to investigate the effect of ERAS implementation in a highly specialized colorectal center.

METHODS

This is a propensity score matched single-center study comparing the short-term outcomes of patients undergoing elective colorectal surgery in a society-indepedent ERAS program from January 2021 to August 2022 to standard perioperative care from January 2019 to December 2020.

RESULTS

Four hundred fifty-six patients were included in the propensity score matched analysis with 228 patients per group (ERAS vs. standard care). Minimally invasive access was used in 80.2% vs. 77.6% (p = 0.88), and there were 16.6% vs. 18.8% (p = 0.92) rectal procedures in the ERAS and standard care group, respectively. Major complications occurred in 10.1% vs. 11.4% (p = 0.65) and anastomotic leakage demanding operative revision in 2.2% vs. 2.6% (p = 0.68) in the ERAS and standard care group, respectively. ERAS lead to a lower number of non-surgical complications compared to standard care (57 vs. 79; p = 0.02). Mean length of stay (LOS) and mean costs per case were lower in ERAS compared to standard care (9.2 ± 5.6 days vs. 12.7 ± 7.4 days, p < 0.01; costs 33,727 ± 15,883 USD vs. 40,309 ± 29,738 USD, p < 0.01).

CONCLUSION

The implementation of an ERAS protocol may lead to a reduction of LOS, costs, and a lower number of non-surgical complications even in a highly specialized colorectal unit using modern surgical and anesthetic care. ( ClinialTrials.gov number NCT05773248).

Impact of COVID-19 Pandemic on Readmission Rates Following Colorectal Surgery: A Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic placed increased pressure to discharge patients early; this could have resulted in rushed discharges requiring patients to return to hospital. The impact of the pandemic on readmission after colorectal surgery is unknown.

METHODS

The National Surgical Quality Improvement Program (ACS-NSQIP) database was used to compare patients undergoing elective colorectal surgery in 2019 and 2020, prior to and during the COVID-19 pandemic. Multivariable logistic regression was used to examine variables associated with readmission. Propensity score matching was then used to compare patients in the pre-pandemic and pandemic cohorts.

RESULTS

A total of 72,874 colorectal cases were included. There were 17.7% less cases in 2020. Rate of readmission was similar in both groups (9.6% vs. 9.4%). There were fewer patients discharged to a facility such as nursing facility or rehabilitation center in 2020, with more patients discharged home. Year was not associated with readmission on multivariable analysis. In the matched cohort, readmission rates did not differ (9.7% vs. 9.3% p = 0.129) nor did mortality (0.8% vs. 0.8% p = 0.686).

CONCLUSIONS

No difference in readmission rates before or during the COVID-19 pandemic was observed; suggesting increased pressure to keep patients out of hospital in the COVID-19 pandemic did not result in patients being rushed home requiring repeat admission. More patients were discharged home with fewer to rehabilitation or nursing facilities in 2020, suggesting success with avoiding transitional services in the right setting.

Artificial intelligence to investigate predictors and prognostic impact of time to surgery in colon cancer

BACKGROUND AND OBJECTIVES

The role of time to surgery (TTS) for long-term outcomes in colon cancer (CC) remains ill-defined. We sought to utilize artificial intelligence (AI) to characterize the drivers of TTS and its prognostic impact.

METHODS

The National Cancer Database was utilized to identify patients diagnosed with non-metastatic CC between 2004 and 2018. AI models were employed to rank the importance of several sociodemographic, facility, and tumor characteristics in determining TTS, and postoperative survival.

RESULTS

Among 518 983 patients, 137 902 (26.6%) received intraoperative diagnosis of CC (TTS = 0), while 381 081 (74.4%) underwent elective surgery (TTS > 0) with median TTS of 19.0 days (interquartile range [IQR]: 7.0-33.0). An AI model, identified tumor stage, receipt of adequate lymphadenectomy, histologic grade, lymphovascular invasion, and insurance status as the most important variables associated with TTS = 0. Conversely, the type and location of treating facility and receipt of adjuvant therapy were among the most important variables for TTS > 0. Notably, TTS was among the most important variables associated with survival, and TTS > 3 weeks was associated with an incremental increase in mortality risk.

CONCLUSIONS

The identification of factors associated with TTS can help stratify patients most likely to suffer poor outcomes due to prolonged TTS, as well as guide quality improvement initiatives related to timely surgical care.

Objective Activity Parameters Track Patient-specific Physical Recovery Trajectories After Surgery and Link With Individual Preoperative Immune States

OBJECTIVE

The longitudinal assessment of physical function with high temporal resolution at a scalable and objective level in patients recovering from surgery is highly desirable to understand the biological and clinical factors that drive the clinical outcome. However, physical recovery from surgery itself remains poorly defined and the utility of wearable technologies to study recovery after surgery has not been established.

BACKGROUND

Prolonged postoperative recovery is often associated with long-lasting impairment of physical, mental, and social functions. Although phenotypical and clinical patient characteristics account for some variation of individual recovery trajectories, biological differences likely play a major role. Specifically, patient-specific immune states have been linked to prolonged physical impairment after surgery. However, current methods of quantifying physical recovery lack patient specificity and objectivity.

METHODS

Here, a combined high-fidelity accelerometry and state-of-the-art deep immune profiling approach was studied in patients undergoing major joint replacement surgery. The aim was to determine whether objective physical parameters derived from accelerometry data can accurately track patient-specific physical recovery profiles (suggestive of a 'clock of postoperative recovery'), compare the performance of derived parameters with benchmark metrics including step count, and link individual recovery profiles with patients' preoperative immune state.

RESULTS

The results of our models indicate that patient-specific temporal patterns of physical function can be derived with a precision superior to benchmark metrics. Notably, 6 distinct domains of physical function and sleep are identified to represent the objective temporal patterns: ''activity capacity'' and ''moderate and overall activity (declined immediately after surgery); ''sleep disruption and sedentary activity (increased after surgery); ''overall sleep'', ''sleep onset'', and ''light activity'' (no clear changes were observed after surgery). These patterns can be linked to individual patients preopera-tive immune state using cross-validated canonical-correlation analysis. Importantly, the pSTAT3 signal activity in monocytic myeloid-derived suppressor cells predicted a slower recovery.

CONCLUSIONS

Accelerometry-based recovery trajectories are scalable and objective outcomes to study patient-specific factors that drive physical recovery.

Comprehensive Evaluation of the Trends in Length of Stay and Post-discharge Complications After Colon Surgery in the USA

INTRODUCTION

With widespread adoption of enhanced recovery protocols and a push toward shorter length of stay (LOS) following colon surgery, the extent to which complications have shifted to the post-discharge setting is unknown. The objectives of this study were to (1) characterize changes in LOS and post-discharge complications over time and (2) evaluate risk factors associated with post-discharge complications.

METHODS

Patients who underwent elective colon resection from 2012 to 2018 were identified from the ACS NSQIP Colectomy-Targeted Dataset. Changes in LOS and the proportion of post-discharge complications were evaluated over time, and predictors of post-discharge complications were assessed using multivariable logistic regression.

RESULTS

Of the 98,136 patients who underwent colon resection, median LOS decreased from 5 days in 2012 to 4 days in 2018. Overall, 30-day complication rate was 21.5%, which decreased during the study period (25.8 to 19.1%, p < 0.001). Of the 13 individual complications evaluated, 4 demonstrated a significant increase in the proportion of post-discharge events including overall SSI (55.8 to 63.3%, p = 0.002), superficial SSI (57.3 to 75.7%, p < 0.001), wound disruption (46.0 to 62.1%, p = 0.047), and UTI (41.5 to 62.7%, p < 0.001). Factors associated with the development of any post-discharge complication included female sex, ASA III/IV/V, dependent functional status, and higher BMI. Intraoperative factors included wound class, operation time, and approach.

CONCLUSIONS

Although LOS and 30-day complications decreased over time, the proportion of events occurring post-discharge increased for several complications. We identified specific factors associated with post-discharge complications which emphasize the importance of a patient monitoring program to early identify and manage post-discharge complications.

Acute urinary retention and urinary tract infection after short-course urinary drainage in colon or high rectum anastomoses: Post hoc analysis of a multicentre prospective database from the GRACE group

AIM

The aim was to define the risk factors for acute urinary retention (AUR) and urinary tract infections (UTIs) in colon or high rectum anastomosis patients based on the absence of a urinary catheter (UC) or the early removal of the UC (<24 h).

METHOD

This is a multicentre, international retrospective analysis of a prospective database including all patients undergoing colon or high rectum anastomoses. Patients were part of the enhanced recovery programme audit, developed by the Francophone Group for Enhanced Recovery after Surgery, and were included if no UC was inserted or if a UC was inserted for <24 h.

RESULTS

In all, 9389 patients had colon or high rectum anastomoses using laparoscopy, open surgery or robotic surgery. Among these patients, 4048 were excluded because the UC was left in place >24 h (43.1%) and 97 were excluded because the management of UC was unknown (1%). Among the 5244 colon or high rectum anastomoses patients included, AUR occurred in 5.2% and UTI occurred in 0.7%. UCs were in place for <24 h in 2765 patients (52.7%) and 2479 did not have UCs in place (47.3%). Multivariate analysis showed that management of the UC was not significantly associated with the occurrence of AUR and that risk factors for AUR were male gender, ≥65 years old, having an American Society of Anesthesiologists score ≥3 and receiving epidural analgesia. Conversely, being of male gender was a protective factor of UTI, while being ≥65 years old, having open surgery and receiving epidural analgesia were risk factors for UTIs. The management of the UC was not significantly associated with the occurrence of UTIs but the occurrence of AUR was a more significant risk factor for UTIs.

CONCLUSION

UCs in place for <24 h did not reduce the occurrence of AUR or UTI compared to the absence of UCs.

Population-Based Assessment of Determining Predictors for Discharge Disposition in Patients with Bladder Cancer Undergoing Radical Cystectomy

Objective: To assess predictors of discharge disposition—either home or to a CRF—after undergoing RC for bladder cancer in the United States. Methods: In this retrospective, cohort study, patients were divided into two cohorts: those discharged home and those discharged to CRF. We examined patient, surgical, and hospital characteristics. Multivariable logistic regression models were used to control for selected variables. All statistical tests were two-sided. Patients were derived from the Premier Healthcare Database. International classification of disease (ICD)-9 (<2014), ICD-10 (≥2015), and Current Procedural Terminology (CPT) codes were used to identify patient diagnoses and encounters. The population consisted of 138,151 patients who underwent RC for bladder cancer between 1 January 2000 and 31 December 2019. Results: Of 138,151 patients, 24,922 (18.0%) were admitted to CRFs. Multivariate analysis revealed that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance are associated with CRF discharge. Rural hospital location, self-pay status, increased annual surgeon case, and robotic surgical approach are associated with home discharge. Conclusions: Several specific patient, surgical, and facility characteristics were identified that may significantly impact discharge disposition after RC for bladder cancer.

Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials

BACKGROUND

Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear.

OBJECTIVE

We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS.

EVIDENCE REVIEW

We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

FINDINGS

Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques.

CONCLUSIONS

Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020161200.

Does implementation and adherence of enhanced recovery after surgery improve perioperative nutritional management in colorectal cancer surgery?

BACKGROUND

Malnutrition is independently associated with poor outcomes in colorectal cancer (CRC) surgery including increased complications and length of stay (LOS). The purpose of this study was to identify changes to perioperative nutritional management and surgical outcomes post implementation of an enhanced recovery after surgery (ERAS) protocol.

METHODS

Data on LOS and adherence to the ERAS protocol, including preoperative fasting time, nutritional assessment and supplementation was prospectively collected for the pre-ERAS group who underwent surgery for CRC between February and August 2019. The post-ERAS group involved a retrospective analysis of prospectively collected data of patients who underwent surgery between October 2019 and July 2020.

RESULTS

One hundred and thirty patients were included, (Pre-ERAS n = 42, Post-ERAS n = 88). A reduction in time to first solid intake by 1 day (P = 0.010), time to first bowel action (P = 0.007) and incidence of nausea (P < 0.001) was seen in the post-ERAS group. Provision of postoperative oral supplements increased from 33.3% to 70.5% (P < 0.001) in the post-ERAS group. Thirteen post-ERAS patients had a ≥ 70% adherence to the ERAS protocol and this subgroup had an associated reduction in LOS, 6.5 (4) days to 5 (3), P = 0.020.

CONCLUSION

Implementation of the ERAS protocol improved perioperative patient care and outcomes. Early feeding was associated with reduced gastrointestinal symptoms without an increase in complications. Adherence to ERAS was associated with a reduction in LOS. Further research is required to evaluate the role of preoperative nutritional screening and intervention within an ERAS protocol.

Application of the Concept of Enhanced Recovery after Surgery in Total Laparoscopic Radical Gastrectomy

To explore the clinical effects of total laparoscopic radical gastrectomy under the guidance of the concept of enhanced recovery after surgery (ERAS). Fifty-five patients were perioperatively treated under the concept of ERAS (ERAS group), while the remaining 55 patients were treated under the traditional perioperative concept (control group). The operation time, intraoperative blood loss, the time of first anal exhaust and first postoperative off-bed activity, postoperative length of stay, and incidence of postoperative complications were recorded in both groups. The pain of patients was assessed using VAS system. The nausea and vomiting and abdominal distension were assessed using the NVDS and abdominal distension score, respectively, within 24 h after operation. The patient's daily living ability was evaluated by the ADL scale at 3 d after the operation. The time of first anal exhaust, the time of first postoperative off-bed activity time, and the postoperative in-hospital time were all significantly shorter in the ERAS group than those in the control group (P < 0.001). The VAS score in the ERAS group was significantly lower than that in the control group at 12 h, 24 h, 48 h, and 72 h after operation (P < .001). The ERAS group had significantly lower NVDS score and abdominal distension score than the control group (P < 0.001). The postoperative ADL score in the ERAS group was significantly higher than that in the control group (P < 0.001). ERAS during the perioperative period of total laparoscopic radical gastrectomy can promote the postoperative rehabilitation of patients and alleviate postoperative pain and gastrointestinal reactions, which is safe and effective.

Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons

BACKGROUND

Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines.

METHODS

A questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX).

RESULTS

Of 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01-9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96-9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83-9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49-9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58-8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17-8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32-8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49-7.66]).

CONCLUSIONS

This survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.

Magnitude and factors associated with preoperative depression among elective surgical patients at University of Gondar comprehensive specialized hospital, North West Ethiopia: A cross-sectional study

Background

Depression one of the world's prevalent mental illnesses is a leading cause of major public health problems globally and its frequency has been increasing, particularly in low and middle-income countries. Little is known about the magnitude and contributing factors of preoperative depression among elective surgical inpatients in the country and in the study area as well. The aim of the current study was to assess the magnitude and factors associated with preoperative depression among elective surgical inpatients.

Method

A cross-sectional study was conducted from May 01, 2021 to June 30, 2021 among preoperative surgical inpatients at University of Gondar comprehensive specialized hospital. Non probability sampling was used. A nine-item questionnaire screening tool was used to assess depression. We computed the bi-variable and multivariable binary logistic regression analyses. Crude and adjusted odds ratio with 95% confidence interval were used.

Result

The magnitude of depression was 28.3%. In the multivariable logistic regression analysis female (AOR = 2.27, 95% CI: 1.15, 4.5), being widowed (AOR = 3.271, 95% CI: 1.25, 8.56), divorced (AOR = 3.41, 95% CI: 1.13, 10.26), length of hospital stay of 7–14 days (AOR = 2.7, 95%CI: 1, 7.2) and more than 14 days (AOR = 3.19, 95% CI: 1.3, 7.8), having co-existing diseases (AOR = 2.78, 95%CI: 1.28, 6.02), current history of pain (AOR = 3.12, 95%CI: 1.6, 5.7), admission to orthopedics (AOR = 3.28, 95%CI: 1.55, 6.95) and gynecology ward (AOR = 2.43, 95% CI: 1.03, 5.7) and poor social support AOR = 2.24, 95% CI: 1.1, 4.6) were significantly associated with depression.

Conclusion

The magnitude of pre-operation depression was 28.3%. Female, Widowed, being divorced, length of hospital stays, coexisting chronic illness, current history of pain, admission at orthopedic and gynecology wards and poor social support were factors significantly associated with depression. We recommend strengthening the linkage of the psychiatric department with preoperative patients to provide psychotherapy behavioral modification.

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Depression is one of the world's mental illnesses problem.

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Little is known about prevalence and its contributing factors of preoperative depression.

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Surgical patients with Preoperative depression have major post-operative complications.

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The prevalence of preoperative depression among surgical inpatient was 28.3%.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Fasting before living-kidney donation: effect on donor well-being and postoperative recovery: study protocol of a multicenter randomized controlled trial

BACKGROUND

One of the main effectors on the quality of life of living-kidney donors is postoperative fatigue. Caloric restriction (CR) and short-term fasting (STF) are associated with improved fitness and increased resistance to acute stress. CR/STF increases the expression of cytoprotective genes, increases immunomodulation via increased anti-inflammatory cytokine production, and decreases the expression of pro-inflammatory markers. As such, nutritional preconditioning by CR or STF represents a non-invasive and cost-effective method that could mitigate the effects of acute surgery-induced stress and postoperative fatigue. To investigate whether preoperative STF contributes to a reduction in fatigue after living-kidney donation, a randomized clinical trial is indicated.

METHODS

We aim to determine whether 2.5 days of fasting reduces postoperative fatigue score in subjects undergoing living-kidney donation. In this randomized study, the intervention group will follow a preoperative fasting regime for 2.5 days with a low-dose laxative, while the control group will receive standard care. The main study endpoint is postoperative fatigue, 4 weeks after living-kidney donation. Secondary endpoints include the effect of preoperative fasting on postoperative hospital admission time, the feasibility of STF, and the postoperative recovery of donor and recipient kidney function. This study will provide us with knowledge of the feasibility of STF and confirm its effect on postoperative recovery.

DISCUSSION

Our study will provide clinically relevant information on the merits of caloric restriction for living-kidney donors and recipients. We expect to reduce the postoperative fatigue in living-kidney donors and improve the postoperative recovery of living-kidney recipients. It will provide evidence on the clinical merits and potential caveats of preoperative dietary interventions.

TRIAL REGISTRATION

Netherlands Trial Register NL9262 . EudraCT 2020-005445-16 . MEC Erasmus MC MEC-2020-0778. CCMO NL74623.078.21.

The application of enhanced recovery after surgery and negative-pressure wound therapy in the perioperative period of elderly patients with colorectal cancer

Objective

To Explore the perioperative application of enhanced recovery after surgery (ERAS) and negative-pressure wound therapy in the elderly patients with colorectal cancer.

Methods

A retrospective clinical data were studied in the patients with colorectal cancer in Department of General Surgery in Shanghai Fourth People,s Hospital (from March, 2017 to March, 2019), One hundred and fifty patients with undergoing radical surgery for colorectal cancer were divided into two groups: ERAS group (n = 76 cases, accepting ERAS management) and Conventional treatment(CT) group (n = 74 cases, accepting traditional treatment), Bleeding in operation, the time of postoperative anal flatus, number of wound dressing changing, time of wound healing, the length of postoperative hospital stay, readmission rate, postoperative complication, were compared between the two groups.

Results

ERAS was associated with less bleeding in operation, less Wound fat liquefaction, less wound dressing changing, less time of wound healing, less time of postoperative anal flatus compare to CT group (P < 0.05); anastomotic fistula, readmission rate is similar in two groups (P > 0.05).

Conclusion

The modified ERAS can be safely applied to the perioperative period of elderly colorectal cancer patients and promote recovery; negative-pressure wound therapy is helpful for wound healing and promoting rehabilitation.

The accumulation of ERAS (enhanced recovery after surgery) components reduces post-colectomy length of stay at small and low volume hospitals

In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an "ERAS designation" and this can be used by small hospitals to improve outcomes.

Enhanced recovery after surgery for sleeve gastrectomies: improved patient outcomes

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care and incorporates patient-centered, evidence-based, and multidisciplinary team-developed pathways for a surgical specialty. ERAS pathways aim to reduce the patient's surgical stress response, optimize their physiologic function, facilitate recovery, and reduce the length of stay. The bariatric program at our institution was previously managed by many surgeons with anecdotal preferences, resulting in increased costs, lengths of stay, and opioid prescribing.

OBJECTIVES

To describe a standardized ERAS pathway for patients undergoing a laparoscopic sleeve gastrectomy procedure in order to enhance perioperative care and reduce opioid usage.

SETTING

ERAS bariatric program in New Jersey.

METHODS

The ERAS bariatric program at our institution was implemented in January 2018. All patients who underwent sleeve gastrectomy from January 2016 to November 2017 (preimplementation) as well as from February 2018 to October 2020 (postimplementation) were included in this retrospective study, with those undergoing procedures in December 2017 and January 2018 excluded due to the transition to the ERAS protocol. Differences in lengths of stay, direct costs, and 30-day readmission rates were compared between the pre- and postimplementation periods. The primary goal of our ERAS pathway was to optimize patient care with reduced opioid usage, and the secondary goal was to reduce the costs for care.

RESULTS

A total of 1988 patients who underwent sleeve gastrectomy were identified, with 789 patients in the preimplementation group and 1199 patients in the postimplementation group. In a multivariate analysis, the mean length of a hospital stay in the postimplementation period was 18% lower (95% confidence interval [CI], 14-22) than that of the preimplementation period (P < .001), while the average opioid morphine milligram equivalents administered in the postoperative period was 61% (95% CI, 57%-65%) less than that of the preimplementation period (P < .001). Average direct costs decreased by $155 (95% CI, -$358 to $48) per case in the postimplementation period (P = .133), and there was no significant difference in the 30-day readmission rate between the pre- and postimplementation periods (3.8% versus 3.0%, respectively; odds ratio, .81; 95% CI, .49-1.35; P = .413).

CONCLUSION

In this study, patient outcomes after ERAS pathway implementation were significantly better than in historical cases. Implementing the bariatric ERAS program for laparoscopic sleeve gastrectomy at our institution has led to rapid postoperative recovery of patients, shorter lengths of stay, reduced opioid usage, and decreased costs per case, thereby increasing the overall cost savings to the hospital. ERAS pathways in bariatric surgery represent an opportunity to enhance patient care while decreasing overall costs. We propose that cost-effective, tailor-made ERAS pathways for sleeve gastrectomy should be implemented in all designated centers of excellence, as they can have a great economic impact on the healthcare system.

Impact of Enhanced Recovery After Surgery on Long-Term Outcomes and Postoperative Recovery in Patients Undergoing Hepatectomy: A Retrospective Cohort Study

Background

The aim of this study was to evaluate the effects of implementation of the enhanced recovery after surgery (ERAS) program on postoperative recovery and the long-term prognosis in patients who underwent hepatectomy.

Methods

This retrospective study enrolled patients who underwent hepatectomy from January 2015 to December 2018 in Huadong Hospital Affiliated to Fudan University. Since June 2016, a 24-point ERAS protocol has been implemented for patients who underwent hepatic resection. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The secondary outcomes included length of stay (LOS), and incidence of postoperative complications.

Results

A total of 1143 patients were enrolled in this study. After propensity score matching (PSM), there was no significant difference in patients' demographic characteristics. The DFS at 1., 3 years in ERAS group was higher than in non-ERAS group (96.3% vs 88.9% for 1 year, P=0.012; 58.9% vs 46.7% for 3 years, P=0.007). The OS at 1, 3 years in ERAS group was higher than in non-ERAS group (93.1% vs 89.3% for 1 year, P=0.041; 68.7% vs 61.2% for 3 years, P=0.035). In addition, the patients in ERAS group had lower incidences of postoperative hemorrhage, bile leak, and postoperative deep vein thrombosis/pulmonary embolism (DVT/PE), decreased 30-day readmission rate and total readmission rate, and shorter LOS.

Conclusion

ERAS program could be safely applied to patients who underwent hepatectomy thereby improving their recovery and prolonging OS and DFS.

Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study

Background

To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards.

Methods

Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days).

Results

Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS.

Conclusions

Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team’s expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.

Studying Enhanced Recovery After Surgery (ERAS®) Core Items in Colorectal Surgery: A Causal Model with Latent Variables

Background

Previous Enhanced Recovery After Surgery (ERAS®) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes.

Method

A causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes (composite of any complication, surgical site infection, medical complications, early ready for discharge (TRD), early actual discharge) and secondary outcomes (composite of late bowel function recovery, IV fluid resumption, nasogastric tube replacement, postoperative nausea and vomiting, re-intervention, re-admission, death) are considered along with their multiple dimensions.

Results

Concerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes.

Conclusion

The multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions.

Cancer Rehabilitation and Palliative Care-Exploring the Synergies

With perpetual research, management refinement, and increasing survivorship, cancer care is steadily evolving into a chronic disease model. Rehabilitation physicians are quite accustomed to managing chronic conditions, yet, cancer rehabilitation remains unexplored. Palliative care physicians, along with rehabilitationists, are true generalists, who focus on the whole patient and their social context, in addition to the diseased organ system. This, together with palliative care's expertise in managing the panoply of troubling symptoms that beset patients with malignancy, makes them natural allies in the comprehensive management of this patient group from the moment of diagnosis. This article will explore the under-recognized and underused parallels and synergies between the two specialties as well as identifying potential challenges and areas for future growth.

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery

OBJECTIVE

To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery.

METHODS

A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018.

RESULTS

A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41).

CONCLUSION

An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Effects of Low Intraperitoneal Pressure on Quality of Postoperative Recovery after Laparoscopic Surgery for Genital Prolapse in Elderly Patients Aged 75 Years or Older

STUDY OBJECTIVE

Previous clinical trials for laparoscopic surgery have included few elderly patients aged ≥75 years. We aimed to evaluate the quality of postoperative recovery after laparoscopic surgery using low intraperitoneal pressure (IPP) (6 mm Hg) and warmed, humidified carbon dioxide gas for genital prolapse in elderly patients aged ≥75 years.

DESIGN

Prospective consecutive case series.

SETTING

University hospital.

PATIENTS

Consecutive patients (n = 30) aged ≥75 years planning to undergo laparoscopic surgery for genital prolapse by the same surgeon were recruited from October 2016 through December 2019.

INTERVENTIONS

Laparoscopic promontofixation for the treatment of genital prolapse was performed using low IPP and warmed, humidified carbon dioxide gas. When a promontory could not be easily identified, laparoscopic pectopexy was alternatively performed.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the Quality of Recovery-40 (QoR-40) score at 24 hours postoperatively. The secondary outcomes were postoperative pain using a 100-mm visual analog scale and the length of hospital stay after surgery (LHSS). For the global QoR-40 score and for 4 dimensions of the QoR-40, "emotional state," "physical comfort," "psychologic support," and "pain," no differences were observed between the baseline score and the score at 24 hours. The score for the "physical independence" dimension at 24 hours was significantly lower than the baseline score (p <.001). No patient had visual analog scale pain scores >30 out of 100 at 12 hours or later. LHSS was <48 hours in 22 patients (73.3%) and <72 hours in 8 patients (26.7%). Multivariable analysis showed that the odds of an LHSS >48 hours were more than 8 times higher in patients who were discharged from the operating room in the afternoon compared with those with a morning discharge.

CONCLUSION

The use of a low IPP is feasible, safe, and has clinical benefits for elderly patients aged ≥75 years who undergo laparoscopic surgery for genital prolapse.

Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery

OBJECTIVE

Thirty percent to sixty-four percent of patients experience poorly controlled pain following spine surgery, leading to patient dissatisfaction and poor outcomes. Identification of at-risk patients before surgery could facilitate patient education and personalized clinical care pathways to improve postoperative pain management. Accordingly, the aim of this study was to develop and internally validate a prediction score for poorly controlled postoperative pain in patients undergoing elective spine surgery.

METHODS

A retrospective cohort study was performed in adult patients (≥ 18 years old) consecutively enrolled in the Canadian Spine Outcomes and Research Network registry. All patients underwent elective cervical or thoracolumbar spine surgery and were admitted to the hospital. Poorly controlled postoperative pain was defined as a mean numeric rating scale score for pain at rest of > 4 during the first 24 hours after surgery. Univariable analysis followed by multivariable logistic regression on 25 candidate variables, selected through a systematic review and expert consensus, was used to develop a prediction model using a random 70% sample of the data. The model was transformed into an eight-tier risk-based score that was further simplified into the three-tier Calgary Postoperative Pain After Spine Surgery (CAPPS) score to maximize clinical utility. The CAPPS score was validated using the remaining 30% of the data.

RESULTS

Overall, 57% of 1300 spine surgery patients experienced poorly controlled pain during the first 24 hours after surgery. Seven significant variables associated with poor pain control were incorporated into a prediction model: younger age, female sex, preoperative daily use of opioid medication, higher preoperative neck or back pain intensity, higher Patient Health Questionnaire-9 depression score, surgery involving ≥ 3 motion segments, and fusion surgery. Notably, minimally invasive surgery, body mass index, and revision surgery were not associated with poorly controlled pain. The model was discriminative (C-statistic 0.74, 95% CI 0.71-0.77) and calibrated (Hosmer-Lemeshow goodness-of-fit, p = 0.99) at predicting the outcome. Low-, high-, and extreme-risk groups stratified using the CAPPS score had 32%, 63%, and 85% predicted probability of experiencing poorly controlled pain, respectively, which was mirrored closely by the observed incidence of 37%, 62%, and 81% in the validation cohort.

CONCLUSIONS

Inadequate pain control is common after spine surgery. The internally validated CAPPS score based on 7 easily acquired variables accurately predicted the probability of experiencing poorly controlled pain after spine surgery.

Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose

Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes.

Methods

Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database.

Results

The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively).

Conclusion

ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Application of Enhanced Recovery After Surgery in Perioperative Period of Tympanoplasty and Mastoidectomy

Introduction:

Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speedup recovery. Tympanoplasty and mastoidectomy are common surgical procedures for chronic suppurative otitis media.

Objective:

To compare the efficacy and safety between ERAS and conventional recovery after surgery in the perioperative period of chronic suppurative otitis media.

Methods:

From April 2018 to February 2019, a total of 84 patients scheduled for tympanoplasty and/or mastoidectomy due to chronic suppurative otitis media were involved and randomly divided into the ERAS group and the control group. The patients’ preoperative anxiety, postoperative pain, and comfort level were determined by comparing the results of Self-Rating Anxiety Scale (SAS), Visual Analog Scale (VAS) and General Comfort Questionnaire (GCQ). The postoperative complications, postoperative hospital stay, and hospitalization cost were calculated.

Results:

The ERAS group showed a lower SAS score (30 [28-31.5] vs 35 [30-43], P < .05], a higher GCQ score (88 [84-100] vs 83 [78.25-92.25], P < .05), and a lower VAS score (0 [0-0] vs 1 [0-2], P < .05] after surgery. No significant difference ( P > .05) was observed between the ERAS group and the control group in postoperative complications, postoperative hospitalization time, and hospitalization cost, respectively.

Conclusion:

Enhanced recovery after surgery can reduce pain and improve comfort in the perioperative period of chronic suppurative otitis media.

Failure of enhanced recovery programs after laparoscopic radical gastrectomy: a single-center retrospective study

BACKGROUND

Enhanced recovery programs (ERPs), as a rapid rehabilitation method, have been widely used in gastric cancer patients. Although many related studies have confirmed their effectiveness, some patients may still experience poor clinical outcomes. This study analyzed risk factors associated with ERP failure after laparoscopic radical gastrectomy.

METHODS

We analyzed the outcomes of 212 patients who underwent ERP following laparoscopic radical gastrectomy between March 2017 and December 2019. The ERP included preoperative education, short periods of fasting, non-mechanical intestinal preparation, early ambulation and oral feeding. ERP failure was defined as more than 7 days of hospitalization due to postoperative complications, unplanned readmission within 30 days of surgery, or death.

RESULTS

The mean patient age was 62 years (range 39-89 years). Surgical procedures included total gastrectomy (n = 161) and distal gastrectomy (n = 51). Overall, 38 (17.9%) patients failed to complete the program, with no mortality. Univariable analysis (P < 0.15) revealed that ERP failure was associated with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, tumor location, preoperative education, combined operation, long operation time, and significant blood loss. Multivariable analysis (P < 0.05) showed that age, ASA grade III, combined operation and preoperative education were independent risk factors for ERP failure.

CONCLUSIONS

We showed that an advanced age, a high ASA grade, lack of a preoperative education and combined surgery were independent risk factors associated with ERP failure after laparoscopic gastrectomy. Therefore, a preoperative patient evaluations and education are important for the success of ERPs.

Perioperative and Postoperative Management of Patients With Crohn's Disease and Ulcerative Colitis

Although the number of available therapies for the treatment of ulcerative colitis and Crohn's disease (CD) continues to expand, a significant portion of patients with inflammatory bowel disease will require surgical intervention. Surgery remains an integral part of the treatment algorithm for patients with ulcerative colitis and CD, and thus multidisciplinary approaches to the perioperative and postoperative management of patients with inflammatory bowel disease are critical to improving outcomes during these periods. New mechanisms of biologic therapies are emerging and new treatment strategies focused on earlier and potentially more aggressive use of immunosuppressive therapies are advocated in the current treatment era. In this review, we outline multidisciplinary strategies for the preoperative management of immunosuppressive therapies, including a discussion of the most recent evidence regarding the safety of biologic therapy in the preoperative period. We also discuss the postoperative medical management of patients undergoing intestinal resection for CD, with a particular focus on risk stratification and appropriate therapy selection in the immediate postoperative setting. Finally, we review potential postoperative complications after restorative proctocolectomy with ileal pouch-anal anastomosis and their management.

Nurses' role in delivering discharge education to general surgical patients: A qualitative study

AIMS

To explore nurses' perceived role and experience in providing discharge education to general surgical patients.

DESIGN

Qualitative, using focus groups and face-to-face individual interviews.

METHODS

Purposive sampling with maximum variation was used to recruit nurses from the general surgical wards in a tertiary hospital in Queensland, Australia. Semi-structured interviews (three focus groups and four individual interviews) were conducted with 21 nurses involved in delivering postoperative discharge education from August 2018 - July 2019. Interview data were analysed using inductive content analysis.

RESULTS

Four themes emerged: assuming responsibility for patient education in the absence of discharge communication; supporting patients to participate in self-management after hospitalization; variability in the resources, content and delivery of discharge education; and meeting operational demands compromises the quality of patients' discharge education.

CONCLUSION

This study highlights the importance of nurses' role and the challenges encountered in delivering effective discharge education. These findings can be used to identify strategies to enhance discharge communication among health professionals and standardize the delivery of education to improve surgical patients' postoperative outcomes.

IMPACT

Ineffective discharge education contributes to patients' poor management of their postdischarge recovery. Developing an understanding of nurses' role in discharge education can inform policies and nursing practice to improve patients' well-being and reduce the potential for unplanned and emergency care.

FACTORS RELATED TO THE REDUCTION OF THE RISK OF COMPLICATIONS IN COLORECTAL SURGERY WITHIN PERIOPERATIVE CARE RECOMMENDED BY THE ACERTO PROTOCOL

Background:

Perioperative care multimodal protocol significantly improve outcome in surgery.

Aim:

To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol.

Methods:

Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions.

Results:

Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day.

Conclusion:

This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.

Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection

BACKGROUND

There is still large debate on feasibility and advantages of fast-track protocols in elderly population after colorectal surgery.

AIM

To investigate the impact of age on feasibility and short-term results of enhanced recovery protocol (ERP) after laparoscopic colorectal resection.

METHODS

Data from 225 patients undergoing laparoscopic colorectal resection and ERP between March 2014 and July 2018 were retrospectively analyzed. Three groups were considered according to patients’ age: Group A, 65 years old or less, Group B, 66 to 75 years old and Group C, 76 years old or more. Clinic and pathological data were compared amongst groups together with post-operative outcomes including post-operative overall and surgery-specific complications, mortality and readmission rate. Differences in post-operative length of stay and adherence to ERP’s items were evaluated in the three study groups.

RESULTS

Among the 225 patients, 112 belonged to Group A, 57 to Group B and 56 to Group C. Thirty-day overall morbidity was 32.9% whilst mortality was nihil. Though the percentage of complications progressively increased with age (25.9% vs 36.8% vs 42.9%), no differences were observed in the rate of major complications (4.5% vs 3.5% vs 1.8%), prolonged post-operative ileus (6.2% vs 12.2% vs 10.7%) and anastomotic leak (2.7% vs 1.8% vs 1.8%). Significant differences in recovery outcomes between groups were observed such as delayed urinary catheter removal (P = 0.032) and autonomous deambulation (P = 0.013) in elderly patients. Although discharge criteria were achieved later in older patients (3 d vs 3 d vs 4 d, P = 0.040), post-operative length of stay was similar in the 3 groups (5 d vs 6 d vs 6 d).

CONCLUSION

ERPs can be successfully and safely applied in elderly undergoing laparoscopic colorectal resection.

[Application of enhanced recovery after surgery in the treatment of children with congenital choledochal cyst]

OBJECTIVE

To explore the feasibility of enhanced recovery after surgery (ERAS) in treatment of children with congenital choledochal cyst.

METHODS

One hundred and thirty children with congenital choledochal cysts admitted in the Children's Hospital of Zhejiang University from June 2017 to June 2019 were divided into ERAS group (n=65) and control group (n=65) according to admission order. The intestinal tract condition during operation, time of operation, surgical results, time for eating after operation, abdominal drainage after operation, length of hospital stay after operation, total hospital expenses and complications were compared between two groups.

RESULTS

Compared with the control group, the satisfaction of intestinal operation field, recovery of gastrointestinal function after operation,time required for the volume of peritoneal drainage fluid to be less than 50 mL,time of abdominal drainage tube removal, and length of hospital stay were all improved in ERAS group (P<0.05 or P<0.01).ERAS group had more peritoneal effusion after removal of abdominal drainage tube (P<0.01), but the incidence of edema after operation was lower (P<0.05). The satisfaction of parents in the two groups was similar, but the cooperation of parents in the ERAS group was improved (P<0.05) and the total cost of hospitalization was reduced (P<0.01).

CONCLUSIONS

ERAS has advantages over the traditional scheme and can be used in the clinical treatment of children with congenital choledochal cyst.

Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis

AIM

This was a prospective cohort study to determine the intrinsic non-modifiable factors influencing length of stay (LOS) in unselected consecutive patients undergoing elective colorectal surgery within an enhanced recovery pathway.

METHODS

This study interrogated a prospective database of consecutive elective procedures from October 2006 to April 2011 at a tertiary referral academic hospital in the UK to identify independent predictors of prolonged length of stay (pLOS). pLOS was defined as longer than median length of stay (mLOS). Differences in determinants were identified in three groups of increasing operative complexity.

RESULTS

In all, 872 procedures were identified and ranged from a simple ileostomy reversal to complex total pelvic exenteration. Preoperative anaemia and American Society of Anesthesiologists (ASA) Grade III+ predicted pLOS in stoma reversal surgery patients (n = 191, mLOS 4 days). In colonic and small bowel surgery (n = 444, mLOS 8 days), an open procedure, new stoma formation, planned critical care admission and ASA III+ predicted pLOS. New stoma formation and planned critical care admission predicted pLOS in patients undergoing pelvic rectal surgery (n = 237, mLOS 11 days). pLOS was associated with significantly higher morbidity across Dindo-Clavien grades and a longer time to postoperative functional recovery and discharge.

CONCLUSIONS

Operative complexity is associated with longer LOS even with an established enhanced recovery pathway in place. Intrinsic non-modifiable predictors of pLOS differ with operative complexity, and this should be taken into account when planning benchmarking and research across units.

Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals

BACKGROUND

Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact.

OBJECTIVE

This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery.

METHODS

An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery.

RESULTS

Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001).

CONCLUSIONS

Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.

Enhanced recovery after surgery protocols in functional endoscopic sinus surgery for patients with chronic rhinosinusitis with nasal polyps: a randomized clinical trial

Background:

Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speed up recovery. This study aimed to assess the impact of ERAS protocols for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

Methods:

One hundred and two patients with CRSwNP undergoing FESS were randomly divided into the ERAS group and the control group. The outcomes of the Self-Rating Anxiety Scale (SAS), Visual Analogue Scale (VAS), Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba Comfort Scale Questionnaire (GCQ) were determined in both groups. The serum levels of C-reactive protein (CRP) were compared preoperatively and 24 hours postoperatively.

Results:

The ERAS group had a significantly better SAS scores than did the control group (28 [24, 35] vs. 43 [42, 47], Z = 5.968, P < 0.001). The rhinalgia and headache scores at 2, 24 and 48 hours postoperatively were lower in the ERAS group than that in the control group (all P < 0.001). The outcomes of the MOS-SS (43 [42, 39] vs. 28 [22, 35], Z = 7.071, P < 0.001) and GCQ (76 [68, 87] vs. 64 [50, 75], Z = 4.806, P < 0.001) were significantly different between the two groups. No significant difference was found in the preoperative CRP levels between the two groups (1.3 [0.6, 2.8] vs. 0.5 [0.5, 1.2], Z = 3.049, P > 0.05); However, the CRP level in 24 hours postoperatively was significantly lower in the ERAS group than that in the control group (2.5 [1.4, 3.9] vs. 6.6 [3.8, 9.0], Z = 5.027, P < 0.001). The incidence rates of complications, such as nausea/emesis (χ² = 0.343, P > 0.05), hemorrhage, aspiration and tumble, were not increased in the ERAS group compared with those in the control group. The ERAS group had a significantly shorter length of hospital stay (5 [4, 5] days vs. 8 [8,9] days, Z = 8.939, P < 0.001) and hospitalization expenses ($ 2670 [2375, 2740] vs. $3129 [3116, 3456], Z = 8.514, P < 0.001).

Conclusions:

ERAS protocols might optimize FESS for patients with CRSwNP by reducing psychological and physical stress, shortening the length of hospital stay and lowering hospitalization expenses without increasing postoperative complications.

Trial registration:

Chinese Clinical Trial Registry, No. ChiCTR1800015791; http://www.chictr.org.cn/showproj.aspx?proj=26872

Application of fast-track surgery in the perioperative period of laparoscopic partial nephrectomy for renal tumors

Objectives

This study aimed to examine application of fast-track surgery (FTS) in the perioperative period of laparoscopic partial nephrectomy for renal tumors, and to discuss its effects and safety.

Methods

Eighty patients who received laparoscopic partial nephrectomy in urinary surgery from January 2016 to December 2017 were selected and randomly classified as the observation group (n = 40) and control group (n = 40). Traditional treatments were performed in the control group, while FTS was applied in the observation group. The complication rate after the operation was recorded.

Results

The duration of the operation and intraoperative blood loss were not different between the groups. The duration of anesthesia and fluid transfusion volume on the day of the operation were significantly less in the observation group than in the control group. The rates of infection of the incisional wound, nausea and vomiting, and anastomotic stomal bleeding were not significantly different between the groups. However, the rates of postoperative urinary tract infection, abdominal distension, thirst, hypothermia, and pulmonary infection were significantly lower in the observation group than in the control group.

Conclusion

Application of FTS in laparoscopic partial nephrectomy contributes to postoperative recovery and reduction of postoperative complications.

Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery

Background

Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery.

Methods

This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression.

Results

Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52).

Conclusion

Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

Does Implementation of Enhanced Recovery after Surgery (ERAS) Protocols in Colorectal Surgery Improve Patient Outcomes?

Enhanced Recovery after Surgery (ERAS) protocols are multimodal perioperative care pathways designed to accelerate recovery by minimizing the physiologic stress of a surgical procedure. Benefits of ERAS implementation in colorectal surgery include reduced length of stay and decreased complications without an increase in readmissions. Though there is evidence associating individual ERAS protocol elements (e.g., preoperative carbohydrate loading, judicious perioperative fluid administration, and early initiation of postoperative nutrition) with improved outcomes, ensuring high compliance with all elements of an ERAS protocol will maximize benefits to the patient. After ERAS implementation, data collection on protocol process measures can help providers target education and interventions to improve protocol compliance and patient outcomes.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways are designed to restore baseline physiology, mitigate surgical stressors, and hasten recovery. Paramount to this approach is optimal pain control through multimodal analgesia and limiting reliance on opioid-based medications. Recent studies have fostered growing controversy surrounding the use of epidural analgesia in the ERAS setting, especially for higher-risk procedures. We examine the analgesic end points associated with the use of epidural within the ERAS framework for open hepatectomy.

METHODS

From November 2013 through March 2016, postoperative analgesic end points including daily morphine equivalent administration and self-reported pain scores were prospectively collected and analyzed for 180 consecutive patients scheduled for open hepatectomy. Patients whose surgeries performed prior to July 2014 were managed using traditional strategy (pre-ERAS, n = 60), and those after July 1 underwent a comprehensive perioperative ERAS pathway (ERAS, n = 120).

RESULTS

Patients managed using the ERAS pathway had a significant reduction in morphine equivalent requirements at 24 hours (median, 10.0 vs 116.0 mg; P < 0.001), 48 hours (median, 10.1 vs 85.4 mg; P < 0.001), and 72 hours (median, 2.5 vs 60.0 mg; P < 0.001) compared with pre-ERAS counterparts with a reduction in average pain scores at 24 hours (numeric pain rating scale, 4.1 ± 1.6 vs 5.1 ± 1.8) and similar scores at other time points. Within ERAS, patients who received epidural (n = 87) required significantly less morphine equivalents at 24 hours (median, 2.7 vs 65.0 mg; P < 0.001) and 48 hours (median, 8.0 vs 50.0 mg; P < 0.001) but not at 72 hours (median, 1.3 vs 4.5 mg; P = 0.56), as well as improved pain scores at 24 hours (visual analog scale score, 3.8 ± 1.3 vs 5.0 ± 1.8; P < 0.001) and 48 hours (3.4 ± 1.8 vs 4.7 ± 1.9; P = 0.001) compared with those who did not receive epidural (n = 33). Other associated postoperative end points including provision of fluids, rates of clinically significant hypotension, and lengths of stay between epidural and nonepidural groups were similar.

CONCLUSIONS

A novel ERAS protocol for open hepatectomy successfully reduced reliance on perioperative opioids without expensing adequate analgesia compared with traditional care. Patients within ERAS benefitted from application of epidural, which further reduced opioid requirements and optimized pain control without increasing complication rates. Epidurals should remain an integral part of ERAS protocols for liver resection surgery.

Predictors of well-being and quality of life in men who underwent radical prostatectomy: longitudinal study1

OBJECTIVE

to identify socio-demographic, clinical and psychological predictors of well-being and quality of life in men who underwent radical prostatectomy, in a 360-day follow-up.

METHOD

longitudinal study with 120 men who underwent radical prostatectomy. Questionnaires were used for characterization and clinical evaluation of the participant, as well as the instruments Visual Analog Scale for Pain, The Ways of Coping Questionnaire, Hospital Depression and Anxiety Scale, Satisfaction with Social Support Scale, Marital Satisfaction Scale, Subjective Well-Being Scale and Expanded Prostate Cancer Index. For data analysis, the linear mixed-effects model was used.

RESULTS

the socio-demographic factors age and race were not predictors of the dependent variables; time of surgery, problem-focused coping, and anxiety were predictors of subjective well-being; pain, anxiety and depression were negative predictors of quality of life; emotion-focused coping was a positive predictor. Marital dissatisfaction was a predictor of both variables.

CONCLUSION

predictor variables found were different from the literature: desire for changes in marital relationship presented a positive association with quality of life and well-being; emotion-focused coping was a predictor of quality of life; and anxiety was a predictor of subjective well-being.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Laparoscopic colorectal surgery and Enhanced Recovery After Surgery (ERAS) program: Experience with 200 cases from a single Italian center

There is increasing evidence that minimally invasive techniques associated with Enhanced Recovery After Surgery (ERAS) protocols reduce surgery-related stress and promote faster recovery after major colorectal surgery. As a single tertiary referral center for colorectal surgery, our aim was to analyze the effects of our ERAS protocol on a heterogeneous population undergoing laparoscopic colorectal surgery.Prospectively collected data from 283 patients undergoing laparoscopic colorectal resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between March 2014 and March 2018 were retrospectively analyzed. Patients' adherence to pre-, intra-, and postoperative ERAS protocol items together with surgical short-term outcomes such as morbidity, mortality, length of hospital stay, and readmission rate was considered.The study protocol was approved by the Ethics Committee of Azienda Ospedaliera Universitaria Integrata di Verona (CRINF-1034 CESC).During the study period, 200 patients met the inclusion criteria and were enrolled in the ERAS protocol. In this series, 34% of patients were aged 70 years or older. Rectal resections represented 26% of all cases, with stoma formation performed in 14.5% of patients. Despite such procedural heterogeneity, good short-term results were obtained: by postoperative day (POD) 2, 58.5% of patients had full return of bowel function, while 63.5% and 88% achieved regular soft diet intake and autonomous walking, respectively. Median (range) length of hospital stay was 5.5 days (2-40) with 71% of patients being discharged by POD 6. No postoperative mortality was recorded, and the rate of major complications was 3.5%. During the study period, 6 patients required redo surgery (3%) and 5 patients required rehospitalization within 30 days (2.5%).This study analyzing the results of the fast-track program in our first 200 cases confirms the feasibility and safety of ERAS protocol application within a heterogeneous population undergoing laparoscopic colonic and rectal resection for benign and malignant diseases.

Preoperative exercise therapy for gastrointestinal cancer patients: a systematic review

BACKGROUND

Gastrointestinal cancer patients are susceptible to significant postoperative morbidity. The aim of this systematic review was to examine the effects of preoperative exercise therapy (PET) on patients undergoing surgery for GI malignancies.

METHODS

In accordance with PRISMA statement, all prospective clinical trials of PET for patients diagnosed with GI cancer were identified by searching MEDLINE, Embase, Cochrane Library, ProQuest, PROSPERO, and DARE (March 8, 2017). The characteristics and outcomes of each study were extracted and reviewed. Risk of bias was evaluated using the Cochrane risk of bias tool by two independent reviewers.

RESULTS

Nine studies (534 total patients) were included in the systematic review. All interventions involved aerobic training but varied in terms of frequency, duration, and intensity. PET was effective in reducing heart rate, as well as increasing oxygen consumption and peak power output. The postoperative course was also improved, as PET was associated with more rapid recovery to baseline functional capacity after surgery.

CONCLUSIONS

PET for surgical patients with gastrointestinal malignancies may improve physical fitness and aid in postoperative recovery.