Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial

Veterinary Enhanced Recovery After Surgery (Vet-ERAS) Program in Dogs Undergoing Emergency Laparotomy

This study aimed to assess the efficacy of a veterinary enhanced recovery after surgery (Vet-ERAS) protocol in dogs undergoing emergency laparotomy (EL). The protocol, adapted from human medicine, encompassed a multidisciplinary approach and interventions such as early goal-directed fluid resuscitation, antibiotic prophylaxis, anti-emetic therapy, multimodal analgesia, and early enteral nutrition. A prospective observational study compared outcomes between dogs managed with the Vet-ERAS protocol (n = 59) and historical controls (n = 82). Implementation of the Vet-ERAS protocol resulted in a significant reduction in perioperative complication rates (p = 0.003) and 15-day mortality (5% vs. 20.7%). Intraoperative complications, including tachycardia and hypothermia, were significantly lower in the Vet-ERAS group. Compliance with the protocol improved over time (p = 0.01). These findings suggest that integrating the Vet-ERAS protocol into perioperative management can improve outcomes in dogs undergoing EL.

Patients' Experience of Nutrition Therapy During Critical Illness and Recovery: A Narrative Review

During critical illness and while recovering, patients may experience varied nutrition interventions, nutrition-impacting symptoms, and challenges relating to the systems of hospital food services. All of these factors can directly impact their experiences and nutrition intake. External factors that may indirectly influence the patient experience of nutrition include family involvement, clinician knowledge and communication, and the hospital environment. The experience of patients during hospitalization may affect behavior and ability to comply with nutrition-related recommendations. However, understanding and including these experiences may help to improve clinical practice, hospital food service systems, and research design.

Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review

INTRODUCTION

Emergency laparotomy (EmLap) is a complex clinical arena, delivering time-sensitive, definitive care to a high-risk patient cohort, with significant rates of post-operative morbidity and mortality. Embedding perioperative care pathways within this complex setting has the potential to improve post-operative outcomes, however, requires an in-depth understanding of their design, delivery and outcome assessment. Delivering and implementing complex interventions such as perioperative pathways require transparent reporting with detailed and indepth description of all components during the assessment and evaluation phase. The aim of this systematic review was to identify the current design and reporting of perioperative pathways in the EmLap setting.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and December 2023. All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways in adult patients (> 18 years old) undergoing major emergency abdominal surgery were included. A narrative description of all perioperative pathways included was reported to identify design and description of the pathway including the delivery and timing of component interventions. All pathways were evaluated against the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Eleven RCTs and 19 non-randomised studies were identified, with most studies considered to be at moderate risk of bias. Twenty-six unique pathways were identified and described, delivering a total of 400 component interventions across 44,055 patients. Component interventions were classified into 24 domains across the perioperative pathway. Twenty studies (66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Two hundred and fifty individual outcomes were reported across pathways, with the most commonly reported outcomes related to morbidity, mortality and length of stay.

CONCLUSION

Current perioperative pathways in EmLap setting are underpinned by variable component interventions, with a lack of in-depth intervention reporting and evaluation. Future studies should incorporate the TIDieR checklist when reporting on perioperative pathways in the EmLap setting.

CLINICAL TRIAL NUMBER

Not applicable.

Enhanced recovery programs following adhesive small bowel obstruction surgery are feasible and reduce the rate of postoperative ileus: a preliminary study

PURPOSE

The recovery of gastrointestinal function and postoperative ileus are the leading goals for clinicians following surgery for adhesive small bowel obstruction. While enhanced recovery programs may improve recovery, their feasibility in emergency surgery has not yet been proven. We sought to assess the incidence of postoperative ileus in patients following surgery for ASBO and the feasibility of enhanced recovery programs, including their benefits in the recovery of gastrointestinal functions and reducing the length of hospitalization.

METHODS

This prospective study includes the first 50 patients surgically treated for ASBO between June 2021 and November 2022. Their surgery was performed either as an emergency procedure or after a short course of medical treatment. The main aim was to compare the observed rate of postoperative ileus with a theoretical rate, set at 40%. The study protocol was registered in clinicaltrials.gov under the number NCT04929275.

RESULTS

Among the 50 patients included in this study, it reported postoperative ileus in 16%, which is significantly lower than the hypothetical rate of 40% (p = 0.0004). The median compliance with enhanced recovery programs was 75% (95%CI: 70.1-79.9). The lowest item observed was the TAP block (26%) and the highest observed items were preoperative counselling and compliance with analgesic protocols (100%). The overall morbidity was 26.5%, but severe morbidity (Dindo-Clavien > 3) was observed in only 3 patients (6%). Severe morbidity was not related with the ERP.

CONCLUSION

Enhanced recovery programs are feasible and safe in adhesive small bowel obstruction surgery patients and could improve the recovery of gastrointestinal functions.

CLINICAL TRIAL REGISTRY

NCT04929275. WHAT DOES THE STUDY CONTRIBUTE TO THE FIELD?: Perioperative management of adhesive small bowel obstruction (ASBO) surgery needs to be improved in order to reduce morbidity. Enhanced recovery programs (ERP) are both feasible and safe following urgent surgery for ASBO. ERPs may improve the recovery of gastrointestinal (GI) functions.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis

BACKGROUND

Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling.

RESULTS

Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001).

DISCUSSION

Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery.

METHODS

A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis.

RESULTS

A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal.

CONCLUSION

ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BACKGROUND

Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways.

AIM

To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters.

RESULTS

Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups.

CONCLUSION

ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

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

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

Enhanced recovery after surgery protocols and emergency surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables.

RESULTS

Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63).

CONCLUSIONS

The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma

BACKGROUND

In patients with blunt injury due to abdominal trauma, the common cause for laparotomy is damage to the small bowel and mesentery. Recently, postoperative early enteral nutrition (EEN) has been recommended for abdominal surgery. However, EEN in patients with blunt bowel and/or mesenteric injury (BBMI) has not been established. Therefore, this study aimed to identify the factors that affect early postoperative small bowel obstruction (EPSBO) and the date of tolerance to solid food and defecation (SF + D) after surgery in patients with BBMI.

METHODS

We retrospectively reviewed patients who underwent laparotomy for BBMI at a single regional trauma center between January 2013 and July 2021. A total of 257 patients were included to analyze the factors associated with enteral nutrition tolerance in patients with EPSBO and the postoperative day of tolerance to SF + D.

RESULTS

The incidence of EPSBO in patients with BBMI was affected by male sex, small bowel organ injury scale (OIS) score, mesentery OIS score, amount of crystalloid, blood transfusion, and postoperative drain removal date. The higher the mesentery OIS score, the higher was the EPSBO incidence, whereas the small bowel OIS did not increase the incidence of EPSBO. The amount of crystalloid infused within 24 h; the amount of packed red blood cells, fresh frozen plasma, and platelet concentrate transfused; the time of drain removal; Injury Severity Score; and extremity abbreviated injury scale (AIS) score were correlated with the day of tolerance to SF + D. Multivariate analysis between the EPSBO and non-EPSBO groups identified mesentery and small bowel OIS scores as the factors related to EPSBO.

CONCLUSION

Mesenteric injury has a greater impact on EPSBO than small bowel injury. Further research is needed to determine whether the mesentery OIS score should be considered during EEN in patients with BBMI. The amount of crystalloid infused and transfused blood components within 24 h, time of drain removal, injury severity score, and extremity AIS score are related to the postoperative day on which patients can tolerate SF + D.

Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery.

METHODS

A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay.

RESULTS

Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles.

CONCLUSIONS

Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency.

AIMS

To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis.

METHODS

This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups.

RESULTS

A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group.

CONCLUSION

Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge.

TRIAL REGISTRATION

Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).

Impact of a Multimodal Analgesia Protocol on Inpatient and Outpatient Opioid Use in Acute Trauma

BACKGROUND

Multimodal analgesia protocols have been implemented after elective surgery to reduce opioid use, however there is limited data on utility after polytrauma. Therefore, we investigated the impact of a multimodal analgesia protocol on inpatient and post-discharge outpatient opioid use after polytrauma.

METHODS

A retrospective review of patients admitted to a Level I trauma center between September 2017-February 2018 (prior to multimodal protocol; "pre-cohort") and October 2018-April 2019 (after multimodal protocol; "post-cohort") was performed. An outpatient controlled substance registry was utilized to capture morphine milligram equivalents (MME) and gabapentin dispensed in the 6 mo after injury.

RESULTS

620 patients were included (295 pre-cohort, 325 post-cohort). Total inpatient MME decreased from 177.5 mg-130 mg (P= 0.01) between the cohorts. Daily inpatient MME decreased from 70.8 mg-44.7 mg (P< 0.01). Intravenous hydromorphone decreased from 2 mg in the pre-cohort to 1 mg in the post-cohort (P= 0.02). Inpatient oxycodone decreased from 45 mg-30 mg (P= 0.01). Concurrently, gabapentin increased from 0 mg-400 mg in the post-cohort (P< 0.01). Patients in the post-cohort were prescribed fewer MMEs than the pre-cohort at discharge (P< 0.05). However, the number of patients prescribed gabapentin increased from 6.1%-16% (P< 0.01).

CONCLUSION

Implementation of an updated multimodal analgesia protocol decreased total MME, daily MME, hydromorphone, and oxycodone consumed while increasing gabapentin use. This suggests that while reducing opioid usage in-hospital is critical to reducing outpatient usage, multimodal pain protocols may lead to an increase in gabapentin prescriptions and utilization after discharge.