Enhanced recovery after surgery: implementing a new standard of surgical care

The Role of Gabapentin in Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Abdominal Procedures, A Systematic Review and Meta-Analysis

Background and Aims

Postoperative pain management remains a significant challenge for patients undergoing abdominal surgery, with poorly managed pain adversely affecting recovery, leading to increased opioid use and associated side effects. Gabapentin, an anticonvulsant, has been proposed as an effective analgesic within enhanced recovery after surgery (ERAS) protocols to minimize opioid consumption and reduce postoperative nausea and vomiting (PONV). However, its role in perioperative pain management lacks consensus, necessitating a systematic review and meta-analysis.

Methods

A systematic review and meta-analysis of randomized controlled trials and observational studies were conducted, following PRISMA guidelines. Databases including PubMed, Scopus, and EMBASE were searched up to August 2024 using terms such as "gabapentin," "postoperative pain," and "ERAS." Studies involving gabapentin or pregabalin in abdominal surgery were included. Pain was assessed using the visual analog scale (VAS), opioid consumption was converted to morphine equivalents, and PONV rates were analyzed. Meta-analysis was performed using STATA 17 software with a random-effects model due to high clinical heterogeneity.

Results

Twenty-two studies with 1812 patients (909 in the gabapentin group and 903 in the control group) were included. Gabapentin significantly reduced postoperative pain (Hedges's g = -1.65, 95% CI: -2.34 to -0.97, p < 0.001) and opioid consumption (Hedges's g = -2.25, 95% CI: -4.29 to -0.20, p = 0.03). Gabapentin also significantly reduced PONV (log OR = -0.67, 95% CI: -1.25 to -0.09, p = 0.02). Adverse effects were mild, including sedation and dizziness.

Conclusion

Gabapentin demonstrates efficacy in reducing postoperative pain, opioid consumption, and PONV in patients undergoing abdominal surgery. Despite substantial heterogeneity across studies, the results suggest gabapentin as a valuable addition to ERAS protocols. Further research is necessary to optimize dosing strategies and address safety concerns, especially regarding sedation in vulnerable populations.

Perioperative enhanced recovery after surgery (ERAS) for non-malignant gynaecological conditions

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of perioperative ERAS protocols compared to traditional perioperative care for women undergoing surgery due to non-malignant gynaecological conditions and to review the availability and key findings of health economic evaluations of ERAS, summarising their principal conclusions.

Adherence to Enhanced Recovery After Surgery (ERAS) With Bellwether Surgical Procedures in Ethiopia: A Retrospective Study

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care approach that aims to improve patient outcomes by reducing physiological stress and promoting organ functional recovery. Implementing ERAS in low-resource settings faces challenges due to limited infrastructure and resources. This study examined the adherence to five ERAS recommendations with Bellwether surgical procedures in Ethiopian surgical facilities.

METHOD

A retrospective database review of the Ethiopian perioperative registry was conducted. A total of 555 patients were included in this study. Data extraction included patient demographics, American Society of Anesthesiologists' Physical Status classification, surgical variables, postoperative hospital length of stay (LOS), and ERAS guidelines components. The primary outcome was adherence to five ERAS guidelines recommendations (early mobilization, feeding initiation, postoperative nausea and vomiting prophylaxis, early catheter removal, and IV fluids discontinuation). The secondary outcomes included: (i) the association between adherence to ERAS guidelines and LOS and (ii) a total unduplicated reach and frequency analysis to determine the two recommendations with the most impact on decreasing LOS for future implementation in low-resource environments.

RESULTS

A total of 555 patients were included across the three surgical categories: CS (274, 49.4%), OBF (126, 22.7%), and laparotomy (155, 27.9%). The primary outcome showed that the overall adherence was 1810 (65.2%) of the total number of the five ERAS guidelines recommendations in the cohort (2275 recommendations). The secondary outcomes showed that adherence to all five ERAS recommendations reduced LOS by 128 h compared to nonadherence to any ERAS elements. Adherence to early mobilization, early removal of urinary catheters, and early feeding each have shown consistent reductions in LOS across all Bellwether surgical procedures.

CONCLUSION

The implementation of a limited set of ERAS recommendations in low-resource environments has the potential to decrease LOS by approximately 5 days for Bellwether surgical procedures.

The Relationship Between Postoperative Outcomes of Gynecologic Patients After Receiving the Enhanced Recovery After Surgery (ERAS) Protocol Versus Narcotic Medication for Pain Management

This retrospective research project will assess the utilization of the Enhanced Recovery After Surgery (ERAS) protocol compared to narcotic treatment in the postoperative course of benign gynecological surgeries. We intend to study the potential relationship between the frequency of readmission rates, deep vein thrombosis (DVT), pulmonary embolism (PE), length of stay, and opioid use in the pre-discharge period in those who receive the ERAS protocol versus narcotics for pain management. The goal is also to increase the implementation of the ERAS protocol in our hospital if it is shown to be superior in this project. We hypothesize that the rate of readmission, frequency of DVT, PE, length of stay, and opioid use in the pre-discharge period will be lower in patients receiving the ERAS protocol. Female patients older than 18 years old who underwent robotic/laparoscopic/abdominal benign gynecologic surgeries in the inpatient setting between 2020 and 2023 in the HCA Florida East Division hospitals were included in this study. The analysis indicates that being in the narcotics group (incidence rate ratio (IRR) = 1.242, p = 0.001) or the ERAS + narcotics group (IRR = 1.886, p < 0.001) is associated with a significantly longer length of stay compared to the ERAS group. A grouped Charlson Index score of 1 (IRR = 1.285, p < 0.001) or 2 or higher (IRR = 2.000, p < 0.001) is also associated with a longer length of stay. Other covariates, including age, race, BMI, and smoking status, did not show statistically significant associations. The results show that being in the ERAS + narcotics group is significantly associated with increased odds of readmission (OR = 3.507, p < 0.001) compared to the ERAS group (readmission is analyzed regardless of specific diagnosis). Older age groups, specifically 45-64 years (OR = 0.574, p = 0.001) and 65 years and over (OR = 0.439, p < 0.001), are associated with lower odds of readmission compared to the 18-44 years group. Older patients may receive more comprehensive care, discharge planning, medications, and follow-ups tailored to their profile, hence returning less compared to the younger group. A grouped Charlson Index score of 1 (OR = 1.692, p = 0.019) or 2 or higher (OR = 3.086, p < 0.001) is significantly associated with increased odds of readmission. We conclude that the utilization of the ERAS protocol compared to narcotic treatment in the postoperative course of benign gynecological surgeries is superior to narcotic treatment and narcotic treatment combined with the ERAS protocol. The ERAS group was associated with shorter length of stay and decreased rates of readmission. Implementing the ERAS protocol as a standard of care is an important step shown to decrease hospital costs, improve patient outcomes, and improve hospital quality.

The Impact of ERAS and Multidisciplinary Teams on Perioperative Management in Colorectal Cancer

INTRODUCTION

The Enhanced Recovery After Surgery (ERAS) protocol, a comprehensive multimodal approach, aims to mitigate surgical stress, expedite recovery, and improve postoperative outcomes. Its implementation has notably advanced perioperative care in colorectal cancer surgeries. Integrating ERAS with multidisciplinary collaboration, involving surgery, anesthesia, nursing, and nutrition, may further enhance patient outcomes, making it a significant focus in clinical practice.

METHODS

This study assessed the effectiveness of integrating the ERAS model with multidisciplinary collaboration during the perioperative period in colorectal cancer patients. A total of 117 patients scheduled for elective surgery at Haiyan People's Hospital between August 2023 and April 2024 were randomly assigned to either a control group (n = 59), receiving traditional care, or an experimental group (n = 58), receiving ERAS-based multidisciplinary care. Key outcomes related to postoperative rehabilitation were evaluated.

RESULTS

Patients in the ERAS group demonstrated significantly shorter hospital stays, quicker catheter removal, and earlier mobilization compared to the control group (P < 0.0001 for all). Additionally, the ERAS group exhibited reduced postoperative inflammatory responses, as indicated by significantly lower interleukin-6 levels on the first postoperative day (P = 0.0247). The quality of life was significantly higher in the ERAS group (P < 0.05). Furthermore, the ERAS group incurred lower total hospitalization expenses than the control group (P = 0.0011).

CONCLUSION

These findings confirm the benefits of the ERAS protocol in enhancing postoperative recovery in colorectal cancer surgeries. The study highlights the importance of a multidisciplinary approach in optimizing patient outcomes and reducing the burden on hospital resources.

Efficacy of Transversus Thoracic Plane Block for Pain Management in Cardiac Surgeries

PURPOSE OF REVIEW

Effective pain management in cardiac surgery presents as a continuous challenge related to the intensity of postoperative pain and reliance on opioid therapy. The dependance of opioid-based therapies is concerning, as these therapies carry risk future addiction and potential severe side effects. The transversus thoracic plane block (TTPB) has emerged as a promising regional anesthesia technique that blocks the anterior branches of the intercostal nerves in the chest wall, potentially providing improved analgesia for cardiac surgery patients. The present investigation evaluates the efficacy of TTPB in reducing opioid consumption, decreasing postoperative pain scores, and enhancing recovery outcomes in patients undergoing cardiac surgeries.

RECENT FINDINGS

Data from randomized controlled trials revealed that TTPB significantly reduced 24-hour opioid consumption, increased the time to first rescue analgesic, and lowered Visual Analog Scale (VAS) pain scores both at rest and with movement, particularly in the first 12 h post-surgery. Additional benefits include fewer opioid-related side effects, such as nausea and pruritus, and reductions in intensive care unit (ICU) length of stay. Studies also suggested that TTPB can support earlier extubation and accelerated recovery, contributing to higher patient satisfaction and overall improved postoperative outcomes.

CONCLUSION

Despite these promising results, challenges in technique standardization and limited long-term data are still obstacles that prevent widespread adoption. Achieving consistent TTPB efficacy requires technical precision in ultrasound guidance, and there is little research on its effectiveness across diverse populations, such as pediatric and high-risk cardiac patients. Addressing these gaps through multi-center, long-term studies could help establish TTPB as a prominent pain management strategy in cardiac surgery to minimize opioid dependence and enhance patient comfort and recovery.

Assessing Use and Familiarity of Enhanced Recovery After Surgery Elements in Pediatric Orthognathic Surgery

Enhanced recovery after surgery (ERAS) protocols have informed perioperative care across multiple surgical specialties, optimizing patient outcomes through surgical stress management and accelerated recovery. This study evaluates the familiarity and adoption of ERAS elements among craniofacial and oral and maxillofacial surgeons in pediatric orthognathic surgery, a field where a formal ERAS protocol has not been established. A closed-ended survey of 102 surgeons was conducted to assess familiarity with and utilization of 14 ERAS elements. The survey garnered a 40.2% response rate, with 41 surgeons participating. The majority of respondents (68.3%) specialized in craniofacial (CF) surgery, and their annual pediatric orthognathic surgery caseload varied widely. Key findings revealed that 7 ERAS elements were widely adopted, including hypothermia prevention, normovolemia maintenance, intraoperative tranexamic acid use, and minimized opioid use for postoperative pain control. However, elements such as liposomal bupivacaine and postoperative goal-directed fluid therapy were less utilized, primarily due to limited availability or knowledge. Surgeons demonstrated high familiarity with elements like jaw immobilization and minimizing opioid use but showed knowledge gaps in areas such as preoperative nutritional screening and goal-directed fluid therapy. These insights underline the need for further education and the development of a standardized ERAS protocol tailored for pediatric orthognathic surgery. The study underscores the importance of multidisciplinary collaboration and comprehensive preoperative education in implementing ERAS protocols. This study serves as a foundation for future research into optimizing perioperative care for pediatric patients undergoing orthognathic surgery.

Synthesis of existing literature on the colorectal surgery patients' challenges during hospital-to-home transitions: a scoping review protocol

INTRODUCTION

Despite advances in innovation to improve patients' transition experiences, it is unclear-in the context of colorectal surgery-what elements of patient education and care could provide the greatest benefit to patient experiences and clinical outcomes. Thus, this scoping review protocol aims to outline a plan to synthesise the existing literature from countries with publicly funded health systems (ie, Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, the United Kingdom and the USA) on the challenges experienced by colorectal surgery patients' when transitioning home from the hospital.

METHODS AND ANALYSIS

This is a protocol for a scoping review to identify literature relating to adult patient challenges experienced when transitioning from hospital to home following colorectal surgery. We will search the following databases for studies published between 2012 and present: Ovid MEDLINE; Ovid Embase; Cochrane Database of Systematic Reviews (Ovid) and Cochrane Central Register of Controlled Trials (Ovid). Title, abstract and full-text review will be conducted independently by at least two reviewers. Data will be extracted, collated, summarised and reported numerically (eg, frequency counts) and presented using descriptive summaries. In addition, data related to the challenges reported by colorectal surgery patients during their transition home from the hospital will be descriptively analysed using deductive content analysis. The extracted challenges will be categorised according to the International Classification of Functioning, Disability and Health and the surgical transition trajectory (eg, predischarge, during discharge and postdischarge) to identify when in the patient journey is the best point to implement improved practices and achieve patient-centred care.

ETHICS AND DISSEMINATION

This protocol does not require ethics approval as data have not been collected or analysed. The findings will highlight insights into patient care transitions following colorectal surgery, which will be disseminated via publications and presentations.

Mechanical Preparation of the Colon before Colorectal Surgery - Is It Still Actual?

Mechanical bowel preparation (MBP) has long been a subject of debate in colorectal surgery. While it was historically regarded as a standard preoperative practice, recent evidence has questioned its necessity and effectiveness, especially when used in isolation. This review explores the evolving role of MBP, its combination with oral antibiotics (OA), and its impact on postoperative outcomes, such as surgical site infections (SSI) and anastomotic leakage (AL). Studies suggest that MBP combined with OA offers superior benefits compared to MBP alone, particularly in left-sided colorectal and rectal surgeries. However, the role of MBP remains contentious in right-sided resections, with conflicting evidence regarding its effectiveness. Furthermore, concerns about patient discomfort, dehydration, and electrolyte imbalances have raised doubts about its routine use. Our comprehensive analysis, based on 11 years of published research, highlights that the decision to employ MBP should be individualized, taking into account the type of surgical intervention, patient comorbidities and overall health status. While MBP+OA shows promise in reducing SSI rates, further research is needed to evaluate its broader clinical implications and to explore alternatives, including newer antibiotics, to minimize reliance on MBP.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Acute Appendicitis: Recommendations for Perioperative Care

Background/Objectives: Acute appendicitis (AA) is one of the most common causes of emergency department visits due to acute abdominal pain, with a lifetime risk of 7-8%. Managing AA presents significant challenges, particularly among vulnerable patient groups, due to its association with substantial morbidity and mortality. Methods: The EUPEMEN (European PErioperative MEdical Networking) project aims to optimize perioperative care for AA by developing multidisciplinary guidelines that integrate theoretical knowledge and clinical expertise from five European countries. This study presents the key elements of the EUPEMEN protocol, which focuses on reducing surgical stress, optimizing perioperative care, and enhancing postoperative recovery. Results: Through this standardized approach, the protocol aims to lower postoperative morbidity and mortality, shorten hospital stays, and improve overall patient outcomes. The recommendations are tailored to address the variability in clinical practice across Europe and are designed to be widely implementable in diverse healthcare settings. Conclusions: The conclusions drawn from this study highlight the potential for the EUPEMEN protocol to significantly improve perioperative care standards for AA, demonstrating its value as a practical, adaptable tool for clinicians.

Implementation of ERAS Protocols: In Theory and Practice

The enhanced recovery after surgery (ERAS) pathway is a perioperative care pathway intended to facilitate early recovery and minimize hospital stays among patients undergoing major surgery. Critical factors for successful ERAS implementation, which may vary depending on care processes, include a multidisciplinary team, organizational commitment to change, and a real-time system for compliance and outcome audits. As most clinicians and health organizations can attest, incorporating and implementing new evidence-based practice changes almost always involves overcoming systemic challenges and obstacles. The same holds true for ERAS programs. The main barriers to ERAS protocol implementation have been resistance to change, lack of time and resources, and inadequate communication and coordination among departments. According to evidence-based ERAS guidelines, the best way to efficiently implement all recommendations into practice is to discover. Implementation science aims to identify and address care gaps, support change in practice, and enhance healthcare quality. Implementation research should also build a robust and generalizable evidence base to inform implementation practice. Most implementation investigations focus on one of two approaches to achieving change. Implementation can progress through top-down or bottom-up processes depending on factors such as national policies, organizational properties, or the implementation culture of society, especially for health issues. Although the ERAS guidelines are based on evidence-based knowledge, only a limited number of health centers around the world have officially been able to implement them. The purpose of this review is to analyze the implementation of the ERAS pathways in theory and practice in Turkey, considering the absence of an ERAS-qualified center in Turkey.

Minimizing Narcotic Use in Rhinoplasty: An Updated Narrative Review and Protocol

Opioids are commonly used to reduce pain after surgery; however, there are severe side effects and complications associated with opioid use, with addiction being of particular concern. Recent practice has shifted to reduce opioid consumption in surgery, although a specific protocol for rhinoplasty is still in progress. This paper aims to expand on the protocol previously established by the senior author based on updated evidence and details. This was accomplished by first high-lighting and summarizing analgesic agents with known opioid-reducing effects in the surgical field, with a particular focus on rhinoplasty, then compiling these analgesic options into a recommended protocol based on the most effective timing of administration (preoperative, intraoperative, postoperative). The senior author's previous article on the subject was referenced to compile a list of analgesic agents of importance. Each analgesic agent was then searched in PubMed in conjunction with "rhinoplasty" or "opioid sparing" to find relevant primary sources and systematic reviews. The preferred analgesic agents included, as follows: preoperative, 1000 mg oral acetaminophen, 200 mg of oral celecoxib twice daily for 5 days, and 1200 mg oral gabapentin; intraoperative, 0.75 μg/kg of intravenous dexmedetomidine and 1-2 mg/kg injected lidocaine with additional 2-4 mg/kg per hour or 1.5 cc total bupivacaine nerve block injected along the infraorbital area bilaterally and in the subnasal region; and postoperatively, 5 mg oral acetaminophen and 400 mg of oral celecoxib. When choosing specific analgesic agents, considerations include potential side effects, contraindications, and the drug-specific mode of administration.

Use of indocyanine green dye for sentinel lymph node mapping in patients with endometrial cancer and a history of iodinated contrast allergy

Objectives

Sentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer.

Methods

IRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics.

Results

820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection.

Conclusions

No patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized.

Evaluating the impact of enhanced recovery after surgery protocols following emergency laparotomy - A systematic review and meta-analysis of randomised clinical trials

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols are an evidence-based, multidisciplinary, and systematic approach to peri-operative care, which attempt to reduce the anticipated physiological strain on patients after major surgery. This meta-analysis of randomised clinical trials (RCTs) evaluated the impact of ERAS following emergency laparotomy versus standard care.

METHODS

A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using RevMan v5.4.

RESULTS

Six RCTs involving 509 patients were included. Patients randomised to ERAS had reduced post-operative nausea and vomiting (PONV) (odds ratio (OR): 0.32, 95 ​% confidence interval (CI): 0.20-0.51), time to ambulation (mean difference (MD): 1.67, 95 ​% CI: -2.56 to -0.78) and bowel opening (MD: -1.26, 95 ​% CI: -2.03 to -0.49), length of stay (LOS) (MD: -2.92 95 ​% CI: -3.73 - - 2.10), pulmonary complications (OR: 0.43, 95 ​% CI: 0.24-0.75), surgical site (OR: 0.33 95 ​% CI: 0.2-0.50) and urinary tract infections (OR: 0.48 95 ​% CI: 0.19-1.16).

CONCLUSION

ERAS successfully reduced patient recovery, LOS, and complications. ERAS protocols should be deployed, where feasible, for emergency laparotomy.

Surgical Technique and Fertility Outcomes: A Comprehensive Review of Open and Laparoscopic Cystectomy in Women of Reproductive Age

Cystectomy, the surgical removal of ovarian tissue, is commonly performed in women of reproductive age to address conditions such as ovarian cysts, endometriosis, and tumors. The choice of surgical technique, open versus laparoscopic, has significant implications for postoperative recovery and long-term fertility outcomes. This comprehensive review aims to evaluate the current literature on the effects of these two surgical approaches on fertility in women of reproductive age. Open cystectomy, while effective, is associated with larger incisions, increased trauma to surrounding reproductive structures, and a higher incidence of postoperative complications, which may negatively impact future fertility. In contrast, laparoscopic cystectomy offers a minimally invasive option that generally results in less postoperative pain, quicker recovery, and potentially improved fertility outcomes due to reduced damage to surrounding tissues. However, the literature reveals a complex interplay between surgical technique, underlying medical conditions, and individual patient factors that can influence reproductive potential. This review synthesizes key studies comparing the fertility outcomes of both surgical methods, highlighting the need for individualized surgical planning based on each patient's unique circumstances and reproductive goals. Additionally, it discusses the importance of preoperative counseling and multidisciplinary approaches to optimize patient outcomes. Future research is essential to further clarify the long-term fertility implications of open and laparoscopic cystectomy and to refine surgical techniques to enhance reproductive health. This review contributes to the growing body of evidence guiding clinicians in making informed decisions that prioritize the effective treatment of ovarian pathology and fertility preservation.

Efficacy of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Colorectal Surgery: A Meta-Analytical Comparison With Conventional Care in Terms of Outcomes and Complications

The "Enhanced Recovery After Surgery" (ERAS) strategy, a patient-centered, evidence-based approach, aims to reduce surgical stress, maintain physiological function, and expedite recovery. Initially developed for elective surgeries, particularly colorectal procedures, ERAS protocols are now being explored for their potential benefits in the more challenging context of emergency surgeries. The current investigation aims to identify the most useful ERAS components in emergency surgery scenarios by comparing postoperative recovery times, possible health outcomes of patients, and complication rates. Through August 2023, extensive searches were conducted in the Cochrane Library, MEDLINE, EMBASE, and PubMed databases. Data were taken from nine RCTs, which were prospective and retrospective cohort studies and were used to derive important outcomes. The Cochrane Risk of Bias tool was employed to measure the caliber of research. Effect pooling estimates were estimated using random-effects models. For the investigations, STATA version 16.0 and Review Manager (RevMan) version 5.4 were used. Nine studies that addressed the range of ERAS components and outcomes were included. Compared to standard treatment, ERAS procedures generally showed faster postoperative recovery durations. Studies' success or adherence rates differed. Subgroup analyses were necessary due to significant heterogeneity in order to determine potential sources. For emergency colorectal procedures, ERAS methods shorten postoperative recovery periods when appropriately modified and put into practice. However, varying success rates throughout studies showed that, in order to maximize and standardize ERAS protocols for comprehensive advantages, significant thought and further study are required. The meta-analysis suggests that ERAS protocols offer substantial benefits in emergency colorectal surgeries, particularly in reducing postoperative recovery times and complication rates.

An update on the perioperative management of postcraniotomy pain

PURPOSE OF REVIEW

Pain after craniotomy is often severe and undertreated. Providing adequate analgesia while avoiding medication adverse effects and physiological complications of pain remains a perioperative challenge.

RECENT FINDINGS

Multimodal pain management includes regional anesthesia and analgesic adjuncts. Strategies aim to reduce or eliminate opioids and the associated side effects. Many individual pharmacologic interventions have been studied with beneficial effects on acute pain following craniotomy. Evidence has been accumulating in support of scalp blockade, nonsteroidal anti-inflammatory drugs (NSAIDs), dexmedetomidine, paracetamol, and gabapentinoids. The strongest evidence supports scalp block in reducing postcraniotomy pain and opioid requirements.

SUMMARY

Improving analgesia following craniotomy continues to be a challenge that should be managed with multimodal medications and regional techniques. Additional studies are needed to identify the most effective regimen, balancing efficacy and adverse drug effects.

An updated systematic review and meta-analysis of the efficacy and safety of early oral feeding vs. traditional oral feeding after gastric cancer surgery

Introduction

Early oral feeding (EOF) has been shown to improve postoperative recovery for many surgeries. However, surgeons are still skeptical about EOF after gastric cancer surgery due to possible side effects. This updated systematic review and meta-analysis aimed to investigate the efficacy and safety of EOF in patients after gastric cancer surgery.

Methods

Randomized controlled trials (RCTs) investigating EOF in patients after gastric cancer surgery were searched in the databases of PubMed, Embase, Clinicaltrials.gov, and Cochrane from 2005 to 2023, and an updated meta-analysis was performed using RevMan 5.4 software.

Results

The results of 11 RCTs involving 1,352 patients were included and scrutinized in this analysis. Hospital days [weighted mean difference (WMD), -1.72; 95% confidence interval (CI), -2.14 to -1.30; p<0.00001), the time to first flatus (WMD, -0.72; 95% CI, -0.99 to -0.46; p<0.00001), and hospital costs (WMD, -3.78; 95% CI, -4.50 to -3.05; p<0.00001) were significantly decreased in the EOF group. Oral feeding tolerance [risk ratio (RR), 1.00; 95% CI, 0.95-1.04; p=0.85), readmission rates (RR, 1.28; 95% CI, 0.50-3.28; p=0.61), postoperative complications (RR, 1.02; 95% CI, 0.81-1.29; p=0.84), anastomotic leakage (RR, 0.83; 95% CI, 0.25-2.78; p=0.76), and pulmonary infection (RR, 0.65; 95% CI, 0.31-1.39; p=0.27) were not significantly statistical between two groups.

Conclusion

This meta-analysis reveals that EOF could reduce hospital days, the time to first flatus, and hospital costs, but it was not associated with oral feeding tolerance, readmission rates, or postoperative complications especially anastomotic leakage and pulmonary infection, regardless of whether laparoscopic or open surgery, partial or total gastrectomy, or the timing of EOF initiation.

Enhanced recovery after surgery and intestinal obstruction: A scoping review

BACKGROUND

Acute intestinal obstruction is a blockage of the intestine which causes a range of clinical symptoms such as acute and severe abdominal pain, nausea, and obstipation. Intestinal obstruction is a medical emergency and can be life-threatening when left untreated. In cases where treatment involves emergency abdominal surgery, a multimodal perioperative care pathway (enhanced recovery after surgery ERAS) has shown to accelerate patient recovery after surgery, reduce hospital length of stay, and improve overall outcomes. The objective of this scoping review was to identify and synthesize the existing evidence regarding the implementation of ERAS components with a focus on postoperative components in patients undergoing surgery for acute intestinal obstruction.

METHODS

This scoping review followed the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews framework. PubMed-Medline and Embase database were searched.

RESULTS

The search identified 1860 studies of which 16 were included in the final analysis. All the studies were quantitative. Eleven studies used 10 or more ERAS interventions (range 10-28). The most common interventions were multimodal systemic analgesia, and the least common were the management of blood glucose and screening tools.

CONCLUSION

This scoping review found that 56% (n = 9/16) of the identified studies used 10 or more ERAS interventions out of a possible 35. This review highlighted the need for studies on the ERAS emergency laparotomy guidelines.

Effectiveness Assessment of Bispectral Index Monitoring Compared with Conventional Monitoring in General Anesthesia: A Systematic Review and Meta-Analysis

Background and Objective. The Bispectral Index (BIS) is utilized to guide the depth of anesthesia monitoring during surgical procedures. However, conflicting results regarding the benefits of BIS for depth of anesthesia monitoring have been reported in numerous studies. The purpose of this meta-analysis and systematic review was to assess the effectiveness of BIS for depth of anesthesia monitoring. Search Methods. A systematic search of Ovid-MEDLINE, Cochrane, and PubMed was conducted from inception to April 20, 2023. Clinical trial registers and grey literature were also searched, and reference lists of included studies, as well as related review articles, were manually reviewed. Selection Criteria. The inclusion criteria were randomized controlled trials without gender or age restrictions. The control groups used conventional monitoring, while the intervention groups utilized BIS monitoring. The exclusion criteria included duplicates, reviews, animal studies, unclear outcomes, and incomplete data. Data Collection and Analysis. Two independent reviewers screened the literature, extracted data, and assessed methodological quality, with analyses conducted using R 4.0 software. Main Results. Forty studies were included. In comparison to the conventional depth of anesthesia monitoring, BIS monitoring reduced the postoperative cognitive dysfunction risk (RR = 0.85, 95% CI: 0.73∼0.99, P = 0.04), shortened the eye-opening time (MD = -1.34, 95% CI: -2.06∼-0.61, P < 0.01), orientation recovery time (MD = -1.99, 95% CI: -3.62∼-0.36, P = 0.02), extubation time (MD = -2.54, 95% CI: -3.50∼-1.58, P < 0.01), and postanesthesia care unit stay time (MD = -7.11, 95% CI: -12.67∼-1.55, P = 0.01) and lowered the anesthesia drug dosage (SMD = -0.39, 95% CI: -0.63∼-0.15, P < 0.01). Conclusion. BIS can be used to effectively monitor the depth of anesthesia. Its use in general anesthesia enhances the effectiveness of both patient care and surgical procedures.

Implementing a nurse-led prehabilitation program for patients undergoing spinal surgery

ABSTRACT

Prehabilitation, or "prehab," helps patients optimize strength, function, and nutrition before surgery. This evidence-based practice project presents strategies for implementing a prehab program to prepare patients for spinal surgery. Nurses play an integral role in educating patients preoperatively about the myriad lifestyle changes associated with spinal surgery.

Optimizing patient-controlled analgesia: a narrative review based on a single center audit process

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

An outline of the management and prevention of postoperative ileus: A review

Postoperative ileus (POI) is a prevalent surgical complication, which results in prolonged hospitalization, patient distress, and substantial economic burden. The literature aims to present a brief outline of interventions for preventing and treating POI post-surgery. Data from 2014 to 2023 were gathered from reputable sources like PubMed, PubMed Central, Google Scholar, Research Gate, and Science Direct. Inclusion criteria focused on studies exploring innovative treatments and prevention strategies for POI, using keywords such as novel POI treatments, non-pharmacological prevention, POI incidence rates, POI management, and risk factors. The findings revealed that integration of preventive measures such as coffee consumption, chewing gum, probiotics, and use of dikenchuto within enhanced recovery programs has significantly reduced both the frequency and duration of POI, without any adverse effects, with minimally invasive surgical approaches showing promise as an additional preventive strategy. While treatment options such as alvimopan, NSAIDs, and acupuncture have demonstrated efficacy, the use of lidocaine has raised concerns due to associated adverse effects. The ongoing exploration of novel therapeutic strategies such as targeting the mast cells, vagal nerve stimulation and tight junction protein, and prokinetic-mediated instigation of the cholinergic anti-inflammatory trail not only holds promise for enhanced treatment but also deepens the understanding of intricate cellular and molecular pathways underlying POI. POI presents a complex challenge in various surgical specialties, necessitating a multifaceted management approach. The integration of preventive and treatment measures within enhanced recovery programs has significantly reduced POI frequency and duration.

Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments

INTRODUCTION

While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability.

METHODS

This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation.

RESULTS

Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups.

CONCLUSIONS

ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod DK, Meshram T, et al. Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia. Indian J Crit Care Med 2024;28(6):626-627.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

The need for standardized perioperative care for patients undergoing bariatric and metabolic surgery in the United Kingdom

Enhanced recovery after surgery (ERAS) protocols are shown to improve patient outcomes and reduce length of hospital stay. However, there is currently limited consensus on the perioperative management of patients undergoing bariatric and metabolic surgery (BMS) in the United Kingdom. This study aims to survey the level of consistency in patient care undergoing BMS. Bariatric nurse specialists from 30 bariatric units completed an anonymised, online survey from 21 December 2022 to 21 February 2023. Most units (77%) have implemented a premade postoperative care bundle protocol including predetermined timing of oral intake (77%) and postoperative day 1 bloods (60%). 63% of units have also established pre-set analgesia and anti-emetic bundles. Date of discharge is variable, ranging from 1 day after surgery (50%) to a 'two night stay' protocol (33%) to within 4 days after surgery (17%). Most follow-up clinics are either led by dietitians (33%) or both bariatric nurse specialists and dietitians collaboratively (57%). Patients are usually established on solid food 6 weeks after surgery in 53% (16/30) units. Chemical venous thromboembolism (VTE) prophylaxis was either given on day of surgery postoperatively (60%), day before (20%) or after (17%) surgery. Our study shows significant variability of care throughout the surgical pathway, in the study population. The results suggest a need for consensus guidelines outlining the best-practice approach to managing patients undergoing BMS; due to the heterogeneity of the patient group, these guidelines should contain overarching generalisable recommendations that can then be tailored to individual patients.

Application of ERAS in older patients with gastric cancer

BACKGROUND

The purpose of this study was to investigate the effectiveness and feasibility of enhanced recovery after surgery (ERAS) in older gastric cancer (GC) patients by observing the changes in postoperative intestinal function recovery, nutritional indicators, and inflammatory markers following the surgery.

METHODS

A total of 61 older GC patients who underwent laparoscopic radical gastrectomy were selected as the subjects of this study. They were divided into an ERAS group (n = 28) and a conventional control group (n = 33) based on the different management modes during the perioperative period. General data, inflammatory response indicators, nutritional indicators, and perioperative indicators of the 2 groups were collected and compared. The changes in relevant indicators were analyzed, and the underlying reasons for these changes were explored.

RESULTS

There were no significant differences in general data and preoperative indicators between the 2 groups (P > .05). In the ERAS group, the inflammatory markers decreased more rapidly, and the nutritional indicators recovered more quickly after surgery. The differences between the 2 groups were statistically significant on the 5th and 7th postoperative days (P < .05). The ERAS group had significantly shorter postoperative hospital stay (10.07 ± 1.41 vs 13.04 ± 3.81), shorter time to first flatus (3.70 ± 0.72 vs 4.18 ± 1.17), shorter drainage tube retention time (8.96 ± 1.53 vs 10.93 ± 3.36), and shorter nasogastric tube retention time (3.36 ± 1.72 vs 6.14 ± 3.99) compared to the control group (P < .05).

CONCLUSION

The application of the ERAS program in older GC patients is effective and feasible, and significantly contributes to faster postoperative recovery in older patients.

The Cost-effectiveness of Enhanced Recovery after Surgery Protocols in Abdominally Based Autologous Breast Reconstruction

Background

The purpose of this study was to conduct a systematic review on the cost-effectiveness of enhanced recovery after surgery (ERAS) protocols in abdominally based autologous breast reconstruction. Further, we reviewed the use of liposomal bupivacaine transversus abdominis plane (TAP) blocks in abdominal autologous reconstruction.

Methods

PubMed, Embase, Cochrane, and Scopus were used for literature review, and PRISMA guidelines were followed. Included articles had full-text available, included cost data, and involved use of TAP block. Reviews, case reports, or comparisons between immediate and delayed breast reconstruction were excluded. Included articles were reviewed for data highlighting treatment cost and associated length of stay (LOS). Cost and LOS were further stratified by treatment group (ERAS versus non-ERAS) and method of postoperative pain control (TAP versus non-TAP). Incremental cost-effectiveness ratio (ICER) was used to compare the impact of the above treatments on cost and LOS.

Results

Of the 381 initial articles, 11 were included. These contained 919 patients, of whom 421 participated in an ERAS pathway. The average ICER for ERAS pathways was $1664.45 per day (range, $952.70-$2860). Average LOS of ERAS pathways was 3.12 days versus 4.57 days for non-ERAS pathways. The average ICER of TAP blocks was $909.19 (range, $89.64-$1728.73) with an average LOS of 3.70 days for TAP blocks versus 4.09 days in controls.

Conclusions

The use of ERAS pathways and postoperative pain control with liposomal bupivacaine TAP block during breast reconstruction is cost-effective. These interventions should be included in comprehensive perioperative plans aimed at positive outcomes with reduced costs.

Unexpected intensive care unit admission after surgery: impact on clinical outcome

PURPOSE OF REVIEW

This review is focused on providing insights into unplanned admission to the intensive care unit (ICU) after surgery, including its causes, effects on clinical outcome, and potential strategies to mitigate the strain on healthcare systems.

RECENT FINDINGS

Postoperative unplanned ICU admission results from a combination of several factors including patient's clinical status, the type of surgical procedure, the level of supportive care and clinical monitoring outside the ICU, and the unexpected occurrence of major perioperative and postoperative complications. The actual impact of unplanned admission to ICU after surgery on clinical outcome remains uncertain, given the conflicting results from several observational studies and recent randomized clinical trials. Nonetheless, unplanned ICU admission after surgery results a significant strain on hospital resources. Consequently, this issue should be addressed in hospital policy with the aim of implementing preoperative risk assessment and patient evaluation, effective communication, vigilant supervision, and the promotion of cooperative healthcare.

SUMMARY

Unplanned ICU admission after surgery is a multifactorial phenomenon that imposes a significant burden on healthcare systems without a clear impact on clinical outcome. Thus, the early identification of patient necessitating ICU interventions is imperative.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Extended-duration thromboprophylaxis following major abdominopelvic surgery - For everyone or selected cases only?

Major abdominopelvic surgery is an important risk factor for postoperative venous thromboembolism (VTE). VTE is the leading cause of 30-day postoperative mortality in patients with cancer undergoing major abdominopelvic surgery. Randomized controlled trials have shown that extended duration thromboprophylaxis using a low molecular weight heparin or a direct oral anticoagulant significantly decreases the risk of overall VTE (symptomatic events and asymptomatic deep vein thrombosis). Hence, several clinical practice guidelines suggest the use of extended duration thromboprophylaxis for all high-risk patients undergoing major abdominopelvic surgery. Despite these recommendations by clinical practice guidelines, adoption of extended duration thromboprophylaxis in clinical practice remains low and clinical equipoise seems to persist. In this narrative review, we aim is to highlight and summarize the reasons that may explain discrepancy between clinical guideline recommendations and current practice regarding extended duration thromboprophylaxis in this patient population. We also aim to review different personalized approaches based on patients' individualized risk of VTE that may foster shared decision making and improve patient outcomes by reducing decisional conflict, increasing patient knowledge, and increasing risk perception accuracy.

Surgical Perspectives of Open vs. Laparoscopic Approaches to Lateral Pancreaticojejunostomy: A Comprehensive Review

Pancreaticojejunostomy, a critical step in pancreatic surgery, has significantly evolved surgical approaches, including open, laparoscopic, and robotic techniques. This comprehensive review explores open surgery's historical success, advantages, and disadvantages, emphasizing surgeons' accrued experience and familiarity with this approach. However, heightened morbidity and prolonged recovery associated with open pancreaticojejunostomy underscore the need for a nuanced evaluation of alternatives. The advent of robotic-assisted surgery introduces a paradigm shift in pancreatic procedures. Enhanced dexterity, facilitated by wristed instruments, allows intricate suturing and precise tissue manipulation crucial in pancreatic surgery. Three-dimensional visualization augments surgeon perception, improving spatial orientation and anastomotic alignment. Moreover, the potential for a reduced learning curve may enhance accessibility, especially for surgeons transitioning from open techniques. Emerging technologies, including advanced imaging modalities and artificial intelligence, present promising avenues for refining both open and minimally invasive approaches. The ongoing pursuit of optimal outcomes mandates a judicious consideration of surgical techniques, incorporating technological advancements to navigate challenges and enhance patient care in pancreaticojejunostomy.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Background and Objective

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods

All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key Content and Findings

Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions

Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Preferred Reporting Of Case Series in Surgery (PROCESS) 2023 guidelines

INTRODUCTION

The Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines were developed in 2016 in order to improve the reporting quality of surgical case series. Since its inception, it has been updated twice, in 2018 and 2020, and has been cited over 1000 times. PROCESS guidelines have enjoyed great acceptance within the surgical research community. Our aim is to update the PROCESS guidelines in order to maintain its applicability in the field of surgical research.

METHODS

A PROCESS 2023 steering group was created. By working in collaboration, members of this group came up with proposals to update the PROCESS 2020 guidelines. These proposals were presented to an expert panel of researchers, who in turn scrutinised these proposals and decided whether they should become part of PROCESS 2023 guidelines or not, through a Delphi consensus exercise.

RESULTS

A total of 38 people participated in the development of PROCESS 2023 guidelines. The majority of items received a score between 7 and 9 from greater than 70% of the participants, indicating consensus with the proposed changes to those items. However, two items (3c and 6a) received a score between 7 and 9 from less than 70% of the participants, indicating a lack of consensus with the proposed changes to those items. Those items will remain unchanged.

DISCUSSION

The updated PROCESS 2023 guidelines are presented with an aim to continue improving the reporting quality of case series in surgery.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Analysis of hospital and payer costs of care: aggressive warming versus routine warming in abdominal major surgery

Background

Hypothermia is common and active warming is recommended in major surgery. The potential effect on hospitals and payer costs of aggressive warming to a core temperature target of 37°C is poorly understood.

Methods

In this sub-analysis of the PROTECT trial (clinicaltrials.gov, NCT03111875), we included patients who underwent radical procedures of colorectal cancer and were randomly assigned to aggressive warming or routine warming. Perioperative outcomes, operation room (OR) scheduling process, internal cost accounting data from the China Statistical yearbook (2022), and price lists of medical and health institutions in Beijing were examined. A discrete event simulation (DES) model was established to compare OR efficiency using aggressive warming or routine warming in 3 months. We report base-case net costs and sensitivity analyses of intraoperative aggressive warming compared with routine warming. Costs were calculated in 2022 using US dollars (USD).

Results

Data from 309 patients were analyzed. The aggressive warming group comprised 161 patients and the routine warming group comprised 148 patients. Compared to routine warming, there were no differences in the incidence of postoperative complications and total hospitalization costs of patients with aggressive warming. The potential benefit of aggressive warming was in the reduced extubation time (7.96 ± 4.33 min vs. 10.33 ± 5.87 min, p < 0.001), lower incidence of prolonged extubation (5.6% vs. 13.9%, p = 0.017), and decreased staff costs. In the DES model, there is no add-on or cancelation of operations performed within 3 months. The net hospital costs related to aggressive warming were higher than those related to routine warming in one operation (138.11 USD vs. 72.34 USD). Aggressive warming will have an economic benefit when the OR staff cost is higher than 2.37 USD/min/person, or the cost of disposable forced-air warming (FAW) is less than 12.88 USD/piece.

Conclusion

Despite improving OR efficiency, the economic benefits of aggressive warming are influenced by staff costs and the cost of FAW, which vary from different regions and countries.

Clinical trial registration

clinicaltrials.gov, identifier (NCT03111875).

Revolutionizing Surgical Care: The Power of Enhanced Recovery After Surgery (ERAS)

The development of Enhanced Recovery After Surgery (ERAS) has brought about substantial transformations in perioperative care, substituting conventional methods with a patient-centric, evidence-based strategy. ERAS protocol adopts a holistic approach to patient care, which includes all stages preceding, during, and following the operation. These programs prioritize patient-specific therapies that are tailored to their specific requirements. Nutritional assessment and enhancement, patient education, minimally invasive procedures, and multimodal pain management are all fundamental components of ERAS. ERAS provides a multitude of advantages, including diminished postoperative complications, abbreviated hospital stays, heightened patient satisfaction, and healthcare cost reductions. This article examines the foundational tenets of ERAS, their incorporation into the field of general surgery, their suitability for diverse surgical specialties, the obstacles faced during implementation, and possible directions for further investigation, such as the integration of digital health technologies, personalized patient care, and the long-term viability of ERAS protocols.

Effects of Scalp Nerve Block on the Quality of Recovery after Minicraniotomy for Clipping of Unruptured Intracranial Aneurysms : A Randomized Controlled Trial

OBJECTIVE

This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB).

METHODS

Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively.

RESULTS

All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044).

CONCLUSION

After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.

Effectiveness of an Educational Intervention with Guidelines from the Total Acceleration of Postoperative Recovery Project (ACERTO) in Gynecology

OBJECTIVE

 To evaluate the effectiveness of an educational intervention among gynecologists about recommendations of the Total Acceleration of Postoperative Recovery (ACERTO, in the Portuguese acronym) project derived from the solid foundations of Enhanced Recovery After Surgery (ERAS) guidelines to optimize hospital care for surgical-gynecological patients.

METHODS

 Educational intervention through monthly 1-hour long meetings (3 months), with the application of an objective questionnaire about specific knowledge of the ACERTO project between before and after educational intervention phases, for gynecologists, after approval by the ethics committee and signature of informed consent by participants, in a federal university hospital.

RESULTS

 Among the 25 gynecologists who agreed to participate, the educational intervention could be effective with a statistically significant difference between the phases before and after the intervention for the main recommendations of the ACERTO project, such as abbreviation of preoperative fasting (p = 0.006), venous thromboembolism prophylaxis (p = 0.024), knowledge and replication of ACERTO (p = 0.034), and multimodal analgesia (p = 0.021).

CONCLUSION

 An educational intervention, through clinical meetings with exposition and discussion of the recommendations of the ACERTO project based on the ERAS protocol can be effective for the knowledge and possibility of practical application of the main measures, such as abbreviation of preoperative fasting, multimodal analgesia, and prophylaxis of thrombosis among gynecologists.

Near-Optimal Recovery Within 3 Months: Investigating Health-Related Quality of Life and Functional Outcomes After Single-Stage Bilateral Hip Replacement for Osteoarthritis

Single-stage bilateral hip replacement (SSBHR) is a safe and successful orthopaedic intervention for patients suffering from bilateral osteoarthritis of the hip. Data on short- and mid-term recovery outcome studies are, unfortunately, scarce. The purpose of this study was to investigate the change in the functional measures and quality of life after SSBHR and to determine the patient's willingness to undergo the same procedure again. Data were prospectively collected and analyzed from patients with bilateral symptomatic hip osteoarthritis who underwent SSBHR from January 2019 until December 2020. Patients were excluded only if they failed to sign an informed consent or were unable to fill out questionnaires due to language or cognitive problems. Preoperatively and 3 and 12 months after surgery, health-related quality of life (HRQOL) and physical functioning were measured. Twelve months after surgery, patient satisfaction (willingness to undergo the same procedure again) was obtained. Complications, blood loss, and length of stay (LOS) were abstracted from the clinical notes and the electronic patient files. Patients improved significantly on all domains of HRQOL (16.0%-59.7%) and physical functioning (14.7%-15.8%) 3 months after surgery in comparison with preoperatively. No improvement was reported on HRQOL and physical functioning, except the Timed Up and Go score (14.1%), at 12 months after surgery in comparison with 3 months. No major or minor complications were found, and LOS was 2.9 days on average. One year after the surgery, all patients expressed satisfaction as suggested by their willingness to undergo the same surgical procedure again. Our study demonstrates that SSBHR offers a rapid recovery time and significant improvements in both functional status and HRQOL within 3 months after surgery. These findings can inform healthcare professionals and patients, suggesting that SSBHR is a viable treatment option for patients with bilateral hip osteoarthritis. Further research, including multicenter randomized controlled trials, is recommended to compare the recovery outcomes of SSBHR with two-stage bilateral hip replacement and confirm our findings.

Quadratus Lumborum Block as a Cornerstone for Neonatal Intestinal Surgery Enhanced Recovery (ERAS): A Case Series

Purpose

Neonates present unique challenges for pediatric surgical teams. To optimize outcomes, it is imperative to standardize perioperative care by using early extubation and multimodal analgesic techniques. The quadratus lumborum (QL) block provides longer duration and superior pain relief than other single-injection abdominal fascial plane techniques. The purpose of this case series was to report our initial experience with QL blocks in neonatal patients treated with intestinal ERAS.

Patients and Methods

Ten neonates requiring intestinal surgery at a single tertiary care center who received QL blocks between December 2019 and April 2022 for enhanced recovery were studied. Bilateral QL blocks were performed with 0.5 mL/kg of 0.25% ropivacaine per side with an adjuvant of 1 mcg/kg of dexmedetomidine.

Results

Gestational age at birth ranged from 32.2 to 41 weeks. The median age, weight, and American Society of Anesthesiologists (ASA) score at the time of surgery was 5 days [range 7.5 hours, 60 days], 2.84 kg [range 1.5, 4.5], and 3, respectively. Bilateral QL blocks were performed without complications in all patients. Two patients were outside the neonatal range from birth to surgery, but were under 42 weeks gestational age when corrected for prematurity. All patients were extubated with well-controlled pain, and no patient required reintubation within the first 24 hours. Postoperatively, median cumulative morphine equivalents were 0.16 mg/kg [range 0, 0.79] and six patients received scheduled acetaminophen. Morphine (0.1 mg/kg) was administered to patients with a modified neonatal infant pain scale (NIPS) score greater than or equal to 4, and pain was reassessed 1 hour after administration (Appendix).

Conclusion

When developing intestinal ERAS protocols, Bilateral QL blocks may be considered for postoperative analgesia in the neonatal population. Further prospective studies are required to validate this approach in neonates.

Enhanced recovery after surgery reduces length of stay after colorectal surgery in a small rural hospital in Ontario

Introduction

Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital.

Methods

A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care.

Results

Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001).

Conclusion

This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.

Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science

PURPOSEOF REVIEW

The purpose of this review is to describe the state of the science of enhanced recovery after surgery (ERAS) in gynecologic oncology.

RECENT FINDINGS

Over the last 5 years, there is mounting evidence supporting ERAS in gynecologic oncology surgery. Despite this, surveys have found suboptimal uptake of ERAS, and stakeholders have highlighted the difficulty of ERAS implementation as a major barrier. To address this, the core components required for a successful ERAS implementation program (protocol, ERAS team, audit system) are reviewed. ERAS developments specific to gynecologic oncology are also discussed, including same-day discharge initiatives for minimally invasive surgery, implications of telemedicine, and methods to increase uptake of ERAS in low- and middle-income countries. ERAS is a surgical quality improvement program with strong evidence supporting its effectiveness in gynecologic oncology. Efforts are required to address ERAS implementation barriers to increase uptake globally, especially in low-income settings.

Implementation of Enhanced Recovery After Surgery protocols for gastrostomy tube insertion in patients younger than 14 years of age: a retrospective cohort study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have improved treatment outcomes and have standardized patient care.

OBJECTIVES

Identify the benefit of introducing the ERAS protocol for feeding after gastrostomy insertion with or without Nissen fundoplication, the effects on the time of reaching the full feeds the length of stay single-center experience, and complications associated with early feeding protocols.

DESIGN

Retrospective cohort study SETTING: Tertiary hospital METHODS: The study review included cases performed between 2015 and 2021 by four surgeons, and cases performed in 2022 by all surgeons using ERAS feeding protocol (P) in a tertiary hospital.

MAIN OUTCOME MEASURES

Comparison the mean and mode of the length of stay (LOS) and the time until the patient reached full feed (TFF).

SAMPLE SIZE

224 patients; 181 by the four surgeons and 43 cases by the ERAS protocol group.

RESULTS

The difference in the ERAS protocol from the four surgeons in TFF and LOS was statistically significant (P<.001). There was no noticeable difference in postoperative complications after introducing the ERAS protocol.

CONCLUSION

ERAS improved the TFF and decreased the LOS without any increase in procedure complications. Increasing bed utilization and reducing costs were two benefits of reducing LOS at our hospital.

LIMITATIONS

Single-center study, which may not be generalizable. Multiple comorbidities. Travel time from different parts of the country could impact LOS. Retrospective and thus dependent on the accuracy of the information in file notes.

CONFLICT OF INTEREST

None.