Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Periprocedural care for frail older patients with aortic stenosis undergoing transcatheter aortic valve replacement

Degenerative aortic stenosis (AS) is an aging-associated disease with alarmingly high mortality that has risen in prevalence in tandem with the global population aging. Treatment options for AS are currently limited to surgical or percutaneous valve intervention, which are associated with significant morbidity. It is increasingly recognized that the care of AS patients is frequently constrained by concomitant frailty, an under-recognized syndrome among older individuals. Many AS patients have concurrent aging-associated diseases, including atherosclerotic diseases, organ impairment, physical frailty, and nutritional deficiencies which limit functional improvement after valve intervention. It has become increasingly crucial for clinicians to address these concurrent issues in frail, older individuals with AS to achieve the best possible outcomes. We aim to review the well-studied relationship between frailty and AS, as well as possible strategies for periprocedural optimization and risk management.

Enhanced recovery after surgery for adolescent idiopathic scoliosis: a revised systematic review and meta‑analysis

PURPOSE

Adolescent idiopathic scoliosis surgery (AIS) is often associated with high costs and significant recovery challenges. Enhanced recovery after surgery (ERAS) protocols aim to improve outcomes, reducing hospital stays and complications compared to traditional (TD) pathways. This study evaluates the impact of ERAS protocols on AIS treatment.

METHODS

Following PRISMA guidelines, a systematic review identified 30 studies (n = 15,954 patients). Search terms included "ERAS," "adolescent idiopathic scoliosis," and "posterior spinal fusion." Outcomes assessed included surgical metrics, recovery milestones, complications, and pain. A meta-analysis was performed, and the risk of bias was evaluated using the MINORS score.

RESULTS

ERAS patients (n = 5582) had shorter surgical durations (- 23 min, p = 0.08) and reduced blood loss (- 126 mL, p = 0.033) compared to TD patients (n = 7916). Recovery milestones improved, including earlier ambulation (- 37.4 h, p < 0.0001), patient-controlled analgesia discontinuation (- 1.1 days, p < 0.0001), catheter removal (- 0.75 days, p < 0.001), and shorter hospital stays (- 1.7 days, p < 0.0001). Complications were lower in the ERAS group (4% vs. 8%, p = 0.0074), while wound-related complications and 30-day readmission rates were comparable. Pain scores were significantly reduced from surgery day to postoperative day 2 (p < 0.0181).

CONCLUSION

ERAS protocols improve recovery and reduce complications in AIS surgery, with shorter hospital stays and enhanced patient outcomes. These findings support broader implementation and further randomized trials to evaluate long-term benefits and patient satisfaction.

Safety of Same-Day Discharge Bariatric Surgery: A Comprehensive Analysis of 457 Cases Across Multiple Procedure Types

BACKGROUND

Outpatient bariatric surgery offers reduced hospital stays and healthcare costs, with promising safety outcomes. This study analyzes the short-term results of stand-alone primary and revision bariatric surgeries, alongside concomitant foregut and abdominal surgeries associated with bariatric procedures, to assess their safety and efficacy in an outpatient setting at a free-standing ambulatory center.

METHODS

A retrospective study was conducted on 457 same-day discharge (SDD) bariatric cases performed by a single surgeon at a free-standing ambulatory center between January 2021 and July 2024. The procedures included sleeve gastrectomy (SG), duodenal switch (DS), adjustable gastric band (AGB) removal, and Roux-en-Y gastric bypass (RYGB). Concomitant foregut and abdominal surgeries associated with bariatric procedures, such as hiatal hernia repair (HHR), cholecystectomy, fundoplication, and ventral hernia repair, were performed when clinically indicated.

RESULTS

Of the 457 cases, 97.8% were primary surgeries, and 2.1% were revisions. Stand-alone procedures accounted for 39.3%, and 60.6% were concomitant. SG constituted 74.8% of cases, followed by HHR (16.1%), DS (5.4%), AGB removal (2.6%), and RYGB (.8%). The mean operative time was 79.9 ± 24.3 min, with a mean length of stay of 3 h 52 min (± 1:10). The 30-day complication rate was 2.1%, with Clavien-Dindo grade IIIb complications in .8% of patients. Patient satisfaction was high, with a mean score of 9.8.

CONCLUSIONS

Outpatient bariatric surgeries demonstrated strong safety with minimal complications, underscoring their viability in carefully selected patients. Staged approaches for complex cases further optimized outcomes, making outpatient settings a robust option for a wide range of bariatric procedures.

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.

Clinical impact of closed-incision negative-pressure therapy in DIEP flap breast reconstruction's donor site

The donor-site wound from deep inferior epigastric perforator flap breast reconstruction differs from abdominoplasty due to higher positioning and tension, potentially affecting healing. Closed-incision negative-pressure therapy has been proposed to improve wound healing and reduce complications. This study aimed to evaluate the impact of this tool on donor-site wound's complications and scar-related patient outcomes. This retrospective cohort study included 140 patients who underwent delayed deep inferior epigastric perforator flap breast reconstruction between September 2020 and March 2023. Patients were assigned to Group A (closed-incision negative-pressure therapy) or group B (micropore tape dressings). Both groups received standardized perioperative care. Complications were analyzed, and scar were assessed 1 year postoperatively using SCAR-Q. Statistical significance was set at p ≤ 0.05. There were no significant differences between the two groups in baseline characteristics. Wound dehiscence was significantly lower in Group A compared to Group B (p = 0.0003). The mean time to wound healing after dehiscence was similar between groups (p = 0.270). No significant differences were found in other complications, such as infection or hematoma. Concerning SCAR-Q, patients in Group A reported significantly better outcomes on the symptom scale (p = 0.03), whereas no significant differences were observed for appearance or psychosocial impact. Closed-incision negative-pressure therapy reduced the rate of wound dehiscence but did not significantly improve scar quality or other complications. Given the limited benefits and lack of cost-effectiveness data, this tool should be considered for further study rather than routine clinical use in low-risk deep inferior epigastric perforator flap patients.

The impact of smoking on postoperative complications following elective off-pump CABG in an ERAS setting

PURPOSE

This study investigates the impact of smoking on major postoperative complications following elective off-pump coronary artery bypass graft (CABG) surgery within an enhanced recovery after surgery (ERAS) program.

METHODS

A total of 3168 patients who underwent elective off-pump and minimally invasive direct CABG under ERAS between January 1, 2017, and December 31, 2020, were enrolled. Propensity score matching was applied to minimize potential confounders when comparing postoperative outcomes between smokers and non-smokers.

RESULTS

Multivariate logistic regression analyses showed no significant difference in 30-day postoperative mortality between smokers and non-smokers (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 0.40-1.56). However, smokers had a higher risk of 30-day major complications, including postoperative acute myocardial infarction (AMI) (aOR: 1.43, 95% CI: 1.02-1.99) and overall postoperative complications (aOR: 1.18, 95% CI: 1.04-1.48). Similarly, for the 31-90-day period, smokers had no significantly higher risk of mortality (aOR: 1.06, 95% CI: 0.49-1.19), but experienced higher rates of major complications, including postoperative AMI (aOR: 1.73, 95% CI: 1.17-2.55) and overall postoperative complications (aOR: 1.48, 95% CI: 1.13-1.92).

CONCLUSIONS

The ERAS program benefits patients undergoing CABG surgery, including smokers, by providing similar major postoperative outcomes to non-smokers, except for increased risks of postoperative AMI and overall complications.

Effect of preoperative oral carbohydrate loading versus oral rehydration solution on enhanced recovery after surgery in elective open gynecological surgeries: A prospective interventional study

Background and Aims

Enhanced recovery after surgery recommends preoperative consumption of carbohydrate within 2 hours before elective surgery to reduce perioperative discomfort and improve patient outcome.

Material and Methods

This prospective interventional study included 105 adult patients, undergoing elective open gynecological surgery under neuraxial anesthesia. Groups I, II, and III were administered commercially available preoperative carbohydrate drink, oral rehydration solution (ORS), and mineral water, respectively, at night and 3 hours before surgery. The primary objective was to assess the difference in hunger, thirst, anxiety, nausea, and fatigue using visual analog scale, postoperative blood sugar levels, and quality of recovery (QoR) 40 questionnaire among groups.

Results

Severe hunger (22.9%), thirst (31.4%), and anxiety (34.3%) were experienced more in group III, while in group I and II, no patient had severe discomfort. The mean blood sugar levels in group III (111.3 ± 12.3, 129.4 ± 7.3) were higher compared to group I and II at both 1 hour and 24 hours after initiation of anesthesia. The mean QoR score was the highest in group I compared to group II and group III (P < 0.001). The majority of the patients in group I (77.1%) had an early return of gastrointestinal function and a shorter length of hospital stay.

Conclusions

The overall effectiveness of commercially available preoperative carbohydrate solution was more compared to ORS and mineral water. The consumption of ORS drink resulted in less thirst and satisfactory outcomes due to its higher electrolyte content, making it a suitable option for low resource setting.

A review of recent advances in anesthetic drugs for patients undergoing cardiac surgery

Inducing and maintaining general anesthesia requires a diverse set of medications. Currently, heart surgery anesthetic management does not adhere to any one standard protocol or set of drugs. To ensure steady circulatory function while providing sufficient sedation, anesthetic medications are carefully selected for cardiovascular operations. Among the opioids used most often in cardiac surgery are fentanyl, sufentanil, and remifentanil. As a cardiac anesthesiologist, your key responsibilities will be to maintain your patient's blood pressure (BP) and oxygen levels, reduce the frequency and intensity of ischemia events, and make it easy for them to get off of cardiopulmonary bypass (CPB) and supplemental oxygen fast. Additionally, new knowledge gaps have been identified as a result of developments in cardiac anesthetics, which must be addressed. The goal of the most recent developments in cardiac anesthesia has been to decrease risks and increase accuracy in patient outcomes during cardiac surgeries. Furthermore, new methods and tools are contributing to the evolution of cardiovascular anesthesia toward a more dynamic, patient-centered approach, with an eye on boosting safety, decreasing complications, and facilitating better recovery for patients. New medications and methods have emerged in the field of anesthetic pharmacology, aiming to improve anesthesia management, particularly for patients who have cardiovascular disease. Optimal cardiovascular stability, fewer side effects, and enhanced surgical recovery are achieved by use of these medications. We have reviewed all the different kinds of cardiac anesthetic techniques and medications in this research. We have also examined the many new anesthetic medicines that have been produced and used for individuals with cardiovascular issues. Next, we covered prospects in the realm of cardiovascular anesthesia and novel cardiac anesthetic drugs.

Understanding Perceptions, Knowledge and Implementation Barriers of Enhanced Recovery After Surgery Among Surgeons and Anesthesiologists

Objective The present study aimed to evaluate the knowledge, perceptions, and barriers associated with Enhanced Recovery After Surgery (ERAS) implementation among perioperative clinicians. Methods This cross-sectional study included responses from 214 perioperative clinicians, comprising surgeons and anesthesiologists involved in abdominal surgeries, from tertiary care hospitals in Khyber-Pakhtunkhwa, Pakistan. A structured questionnaire collected data on participants' knowledge of ERAS protocols, perceived barriers to implementation, and learning preferences. Responses were analyzed using descriptive and inferential statistics, with significance set at p<0.05. Results This study included 214 perioperative clinicians, predominantly residents (91.6%, n=196), from surgery (90.2%, n=193) and anesthesiology (9.8%, n=21) departments. Knowledge about ERAS protocols was limited, with 89 (41.6%) of respondents stating they knew nothing and 97 (45.3%) reporting very little or some familiarity. Perceived barriers included lack of institutional support, time constraints, and insufficient research. Most participants, 145 (67.8%), supported integrating ERAS education into formal training, with 92 (42.9%) favoring seminars or lectures and 79 (36.9%) preferring journal articles for learning. Perceptions of ERAS importance were generally positive, but significant differences were noted regarding hospital administration support (p=0.013). Conclusion This study identifies significant gaps in ERAS knowledge among perioperative clinicians, particularly among residents, and highlights perceived logistical barriers to its implementation. However, the findings are limited by the underrepresentation of consultants and anesthesiologists, who are key drivers of ERAS programs. The findings highlight the need for targeted educational interventions, stronger institutional support, and multidisciplinary collaboration to improve ERAS adoption.

The evolution and key components of oncoanaesthesia: a narrative review

INTRODUCTION

Oncoanaesthesia is a specialised branch of anaesthesia dedicated to enhancing outcomes, prioritising patient safety and improving the overall care of patients with cancer during surgery. We outline the global epidemiology of cancer, emphasising the necessity for this subspecialty, and discuss the criteria supporting its establishment.

METHODS

We performed searches of electronic databases to identify relevant peer-reviewed publications. The search was designed to capture a wide range of study types, including randomised controlled trials; retrospective studies; meta-analyses; and systematic reviews. The titles and abstracts were screened to identify publications relevant to oncoanaesthesia, cancer recurrence and return to intended therapy. The reference lists were manually reviewed to identify relevant papers for consideration.

RESULTS

This review highlights the growth of oncoanaesthesia over the past decade. Research opportunities abound in areas such as: the impact of anaesthesia on cancer recurrence; the use of enhanced recovery after surgery programmes; patient blood management; peri-operative nutrition; techniques for modulating peri-operative inflammatory responses; and strategies to reduce the time to return to intended oncological treatment.

DISCUSSION

By integrating various subspecialties within oncology centres, oncoanaesthesia ensures a thorough and holistic approach to both curative and palliative cancer care, ultimately improving patient outcomes and providing better support for families and caregivers throughout the peri-operative period.

Analysis of ERAS protocol adherence and postoperative outcomes after major colorectal surgery in a community hospital

Despite widespread adoption, the efficacy of Enhanced Recovery After Surgery (ERAS) protocols in community hospital settings remains understudied. This retrospective analysis conducted at a high-volume community hospital aimed to evaluate adherence to ERAS protocols and analyze postoperative outcomes following colorectal surgery. A total of 278 adult patients undergoing elective colorectal surgery between January 2022 and January 2024 were included. Data analysis revealed time to first mobilization proved to be satisfactory in accordance with ERAS hospital guidelines (mean 1.0 ​± ​0.05 days, range 0.1-13.8 days), and furthermore demonstrated a strong positive correlation with both time to first bowel function (r ​= ​0.69, p ​< ​0.0001) and length of stay (r ​= ​0.25, p ​< ​0.0001). Time to urinary catheter removal occurred slightly after guideline-directed removal (mean 1.1 ​± ​0.05 days, range 0.5-12.9 days), however did exhibit a significant positive correlation with length of stay (r ​= ​0.33, p ​< ​0.0001). 10.9 ​% of patients experienced a postoperative complication, while the average length of stay across all procedures was 3.1 ​± ​0.17 days (range 0.9-23.3 days), and the overall 30-day readmission rate stood at 10.43 ​%. This study underscores the need for ongoing evaluation and refinement of ERAS protocols in community hospital settings to enhance surgical care and patient satisfaction.

Optimizing Surgical Outcomes: The Role of Enhanced Recovery After Surgery (ERAS) Protocols in Improving Recovery and Reducing Hospital Stays in Pakistan

Background Enhanced recovery after surgery (ERAS) procedures are increasingly recognized for their ability to improve surgical outcomes and shorten hospital stays, particularly in resource-constrained environments like Pakistan. This study underscores the transformative potential of ERAS protocols in not only enhancing patient recovery but also optimizing healthcare resource utilization in such settings. The research aimed to evaluate the effectiveness of ERAS protocols in reducing postoperative complications and hospital stays among surgical patients in Pakistan, with a focus on their impact on overall recovery and healthcare efficiency. Methodology A prospective cohort design was employed, recruiting 400 adult patients aged 18 years and older undergoing elective surgical procedures from January to December 2023. Data on demographics, adherence to ERAS procedures, postoperative complications, duration of hospital stay, and recovery metrics were gathered before, during, and after surgery for participants who were split into ERAS and standard care groups. To compare results between groups, statistical procedures such as t-tests and chi-square tests were used. Results The ERAS group exhibited a significantly shorter mean length of hospital stay (3.52 ± 1.27 days) compared to the standard care group (6.29 ± 2.15 days, p < 0.001). Full recovery rates at 30 days, three months, and six months were significantly higher in the ERAS group, with 160 patients (80.0%), 178 patients (89.0%), and 191 patients (95.5%), respectively. In contrast, the standard care group showed recovery rates of 122 patients (61.0%), 147 patients (73.5%), and 164 patients (82.0%) at the same intervals. The ERAS group also had lower rates of postoperative complications, with 176 patients (88.0%) experiencing no complications compared to 152 patients (76.0%) in the standard care group, and lower readmission rates, with nine patients (4.5%) compared to 19 patients (9.5%) in the standard care group. Conclusion The successful implementation of ERAS procedures in Pakistan highlights their potential to improve healthcare efficiency by increasing surgical recovery and lowering hospital stays.

ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.

Risk factors for postoperative acute kidney injury after radical cystectomy for bladder cancer in the era of ERAS protocols: A retrospective observational study

BACKGROUND

Radical cystectomy (RC) is a major surgery associated with a high morbidity rate. Perioperative fluid management according to enhanced recovery after surgery (ERAS) protocols aims to maintain patients in an optimal euvolemic state while exposing them to acute kidney injury (AKI) in the event of hypovolemia. Postoperative AKI is associated with severe morbidity and mortality. Our main objective was to determine the association between perioperative variables, including some component of ERAS protocols, and occurrence of postoperative AKI within the first 30 days following RC in patients presenting bladder cancer. Our secondary objective was to evaluate the association between a postoperative AKI and the occurrence or worsening of a chronic kidney disease (CKD) within the 2 years following RC.

METHODS

We conducted a retrospective observational study in a referral cancer center in France on 122 patients who underwent an elective RC for bladder cancer from 01/02/2015 to 30/09/2019. The primary endpoint was occurrence of AKI between surgery and day 30. The secondary endpoint was survival without occurrence or worsening of a postoperative CKD. AKI and CKD were defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification. Logistic regression analyse was used to determine independent factors associated with postoperative AKI. Fine and Gray model was used to determine independent factors associated with postoperative CKD.

RESULTS

The incidence of postoperative AKI was 58,2% (n = 71). Multivariate analysis showed 5 factors independently associated with postoperative AKI: intraoperative restrictive vascular filling < 5ml/kg/h (OR = 4.39, 95%CI (1.05-18.39), p = 0.043), postoperative sepsis (OR = 4.61, 95%CI (1.05-20.28), p = 0.043), female sex (OR = 0.11, 95%CI (0.02-0.73), p = 0.022), score SOFA (Sequential Organ Failure Assessment) at day 1 (OR = 2.19, 95%CI (1.15-4.19), p = 0.018) and delta serum creatinine D1 (OR = 1.06, 95%CI (1.02-1.11), p = 0.006). During the entire follow-up, occurrence or worsening of CKD was diagnosed in 36 (29.5%). A postoperative, AKI was strongly associated with occurrence or worsening of a CKD within the 2 years following RC even after adjustment for confounding factors (sHR = 2.247, 95%CI [1.051-4.806, p = 0.037]).

CONCLUSION

A restrictive intraoperative vascular filling < 5ml/kg/h was strongly and independently associated with the occurrence of postoperative AKI after RC in cancer bladder patients. In this context, postoperative AKI was strongly associated with the occurrence or worsening of CKD within the 2 years following RC. A personalized perioperative fluid management strategy needs to be evaluated in these high-risk patients.

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.

Prehabilitation to Enhance Vascular Surgery Outcomes: A Narrative Review

Prehabilitation, an emerging strategy, prepares patients for elective surgery by encouraging healthy behaviors, including physical exercise and healthy nutrition, while providing psychological support, to improve postoperative outcomes and foster healthier lifestyles. Despite growing interest, there is little research on prehabilitation. Specifically, studies involving prehabilitation in vascular surgery are heterogeneous with small sample sizes. This review aimed to investigate the reported positive impact of prehabilitation on vascular surgery patients, discuss prehabilitation models, highlight prehabilitation program-associated challenges, and suggest appropriate interventions. Prehabilitation improves physical fitness, reduces postoperative complications, and enhances overall recovery. Multimodal prehabilitation programs can positively impact vascular surgery patients, with benefits including improved cardiovascular fitness, reduced postoperative complications, shorter postoperative hospital stays, enhanced overall recovery, and improved quality of life. The currently reported prehabilitation programs are heterogeneous, with limitations regarding patient adherence and lack of long-term outcomes, posing challenges to their widespread adoption. Overall, prehabilitation shows promise for improving vascular surgery outcomes and fostering long-term healthy behaviors. The systematic implementation of prehabilitation in vascular surgery care pathways, overcoming reported limitations, and integrating multimodal prehabilitation into routine preoperative care hold potential benefits. This review underscores the need for high-quality research to establish best practices in prehabilitation and integrate them into the standard of care for vascular surgery patients.

Propofol Versus Dexmedetomidine for Conscious Sedation During Vaginal Hysterectomy With Pre-emptive Local Anesthesia: A Prospective Cohort Study

BACKGROUND/AIM

Hysterectomy is the most frequent gynecological surgery. Vaginal hysterectomy (VH) seems to be related to favorable perioperative outcomes compared to abdominal or laparoscopic approaches. As the population ages, anesthesia that is safer for the elderly, such as local anesthesia (LA) with conscious sedation, is gaining popularity and is related to favorable outcomes in patients' recovery compared to general or regional anesthesia. We aimed to evaluate the efficacy of dexmedetomidine versus propofol for women undergoing VH for uterine prolapse under LA and conscious sedation.

PATIENTS AND METHODS

A prospective study on 40 women with uterine prolapse stage ≥3 who had VH under LA with conscious sedation under either dexmedetomidine (n=20) or propofol (n=20) was performed. A standardized surgical approach with continuous hemodynamic monitoring and sedation assessment using the Ramsay Sedation Scale (RSS) was conducted. The primary endpoint of the study was to determine the percentage of patients receiving intraoperative fentanyl.

RESULTS

Analysis of outcomes demonstrated a significant reduction in the proportion of patients requiring intraoperative rescue fentanyl (35% vs. 5%, respectively, p=0.04) and in postoperative pain scores, with more patients achieving an optimal RSS score of 3 in the dexmedetomidine group.

CONCLUSION

Based on the findings of the present study, dexmedetomidine offered superior analgesia and patient comfort compared to propofol, suggesting a favorable anesthetic profile for VH under LA.

Anesthetic Management of a Patient With Wolff-Parkinson-White Syndrome Undergoing Gynecological Robotic Surgery

Robotic surgery provides precision and safety for minimally invasive gynecological operations but introduces unique anesthetic challenges, especially for individuals with pre-existing conditions like Wolff-Parkinson-White (WPW) syndrome. This case report addresses the anesthetic management of a 32-year-old female with WPW syndrome undergoing a myomectomy. A thorough pre-operative evaluation, including an ECG, echocardiogram, and Holter monitoring, was performed to assess the anesthetic and cardiac risks. The patient was administered a combination of loco-regional and general anesthesia, with an emphasis on neuromuscular monitoring, antiarrhythmic preparedness, and pain management to effectively manage the complexities introduced by WPW syndrome and robotic surgery. The anesthetic protocol comprised premedication with midazolam, induction using sufentanil, propofol, and rocuronium, and maintenance with desflurane, along with techniques to mitigate the effects of pneumoperitoneum and Trendelenburg positioning. Employing these strategies, the surgery concluded successfully without any anesthetic or surgical complications. The patient experienced a rapid and complete awakening, achieved optimal pain control, and was able to mobilize early, leading to her discharge 24 hours post-surgery. This case demonstrates the essential nature of customized anesthetic management for patients with WPW syndrome undergoing robotic surgery. It underscores the necessity of an exhaustive pre-operative assessment, diligent intraoperative monitoring, and active postoperative care to ensure patient safety and promote swift recovery.

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

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

SUPPLEMENTARY INFORMATION

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

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

Impact of Covid-19 Pandemic on Waitlisted Preoperative General Surgical Patients in a Tertiary Care Hospital in India - Problems and Probable Solutions: an Observational Study

INTRODUCTION

Among patients affected by Covid-19, a large subset included those who were on preoperative general surgical waiting list for elective operations. There are very few studies on the various factors that impacted these patients during the pandemic in India. The current study aimed to analyse the factors which hampered the surgical management of such patients and to suggest implementable solutions which can mitigate those factors in future pandemics.

MATERIALS AND METHODS

This was a cross sectional observational study conducted from March 2021 to February 2022. Patients from the surgical register who were placed on a waiting list for routine elective procedures like hernias, gallstone disease, benign thyroid swellings, etc were included, while those with malignancy and emergencies were excluded. We sought information about their current status regarding the planned surgery, the factors which have prevented or are preventing them from accessing suitable surgical service and the current status of individually experienced symptoms.

RESULTS

There were 38 respondents. Most of the patients belonged to the age group 40-60 years and had an average waiting period of more than six months. In 20/38 patients, surgery was postponed because of Covid-19 pandemic, seven patients were admitted but operation was postponed for various reasons, while a few others suffered due to financial difficulty or lockdown restrictions. In 23/38 patients' symptoms progressed and nine patients had unbearable symptoms at the time of the study. Two of the 38 respondents underwent emergency surgery outside the institute. All subjects knew that Covid-19 patients were being treated in the institute, where most of them were still willing to continue their treatment. Three patients refused to continue treatment because of apprehension about getting Covid-19.

CONCLUSION

Although the World Health Organization (WHO) declared the Covid-19 pandemic over, experts opine that there might be more such incidents in not-too-distant future. Our study is among the few of its kind that provides some analytical data regarding the factors which prevented the general surgical patients access to surgical service in India during the Covid-19 pandemic and to suggest some implementable strategies to mitigate the effect of those factors in future pandemics.

Safety and Feasibility of Enhanced Recovery after Surgery in Pediatric Colostomy Closure

Aims

To study the safety and feasibility of enhanced recovery after surgery (ERAS) protocol in pediatric colostomy closure.

Materials and Methods

Retrospective observational study of children who underwent colostomy closure. Data were collected from the electronic medical records and telephonic follow-up calls of patients from October 2013 to October 2023, in the Department of Pediatric Surgery of a Tertiary level Medical College. The parameters obtained were age, gender, type of stoma, primary diagnosis, discrepancy in luminal diameters, time to reach full feeds, postoperative hospital stay, and complications. The protocol followed for colostomy closure included the following-no bowel preparation or nasogastric tube, no overnight fasting, single dose of antibiotic prophylaxis, avoiding opioids, packing proximal stoma till mobilization and starting early oral feeds postoperatively. The continuous parameters were expressed as mean ± standard deviation or median (range) while the descriptive parameters were expressed as number and percentage.

Results

A total of 90 patients were included in the study. Most of the patients had colostomy for anorectal malformation. Five of them had significant luminal discrepancy of 4 or more times. Full feeds were reached within 2 days in 79 patients. Postoperative hospital stay was 2-3 days in 62 patients. Six patients stayed for more than 5 days, due to complications requiring further management. We noted surgical site infection in 6 patients all of whom were managed with regular wound dressings and fecal fistula in 4 cases, two of which resolved spontaneously.

Conclusion

ERAS protocol in colostomy closure reduces the hospital stay and is cost effective, with early recovery and no added complications.

Enhanced recovery after chest wall resection and reconstruction: a clinical practice review

Since the late 1990s, and Henrik Kehlet's hypothesis that a reduction of the body's stress response to major surgeries could decrease postoperative morbidity, "Enhanced Recovery After Surgery" (ERAS) care pathways have been streamlined. They are now well accepted and considered standard in many surgical disciplines. Yet, to this day, there is no specific ERAS protocol for chest wall resections (CWRs), the removal of a full-thickness portion of the chest wall, including muscle, bone and possibly skin. This is most unfortunate because these are high-risk surgeries, which carry high morbidity rates. In this review, we propose an overview of the current key elements of the ERAS guidelines for thoracic surgery that might apply to CWRs. A successful ERAS pathway for CWR patients would entail, as is the standard approach, three parts: pre-, peri- and postoperative elements. Preoperative items would include specific information, targeted patient education, involvement of all members of the team, including the plastic surgeons, smoking cessation, dedicated nutrition and carbohydrate loading. Perioperative items would likely be standard for thoracotomy patients, namely carefully selective pre-anesthesia sedative medication only in some rare instances, low-molecular-weight heparin throughout, antibiotic prophylaxis, minimization of postoperative nausea and vomiting, avoidance of fluid overload and of urinary drainage. Postoperative elements would include early mobilization and feeding, swift discontinuation of intravenous fluid supply and chest tube removal as soon as safe. Optimal pain management throughout also appears to be critical to minimize the risk of respiratory complications. Together, all these items are achievable and may hold the key to successful introduction of ERAS pathways to the benefit of CWR patients.

A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption.

PURPOSE

The study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery.

MATERIALS AND METHODS

This study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols.

RESULTS

The analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported.

CONCLUSION

The prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.

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.

Views and experiences of healthcare professionals and patients on the implementation of a 23-hour accelerated enhanced recovery programme: a mixed-method study

BACKGROUND

An accumulating body of research suggests that an accelerating enhanced recovery after colon surgery protocol is beneficial for patients, however, to obtain these effects, adherence to all elements of the protocol is important. The implementation of complex interventions, such as the Enhanced Recovery After Surgery protocol (ERAS), and their strict adherence have proven to be difficult. The same challenges can be expected in the implementation of the accelerated Enhanced Recovery Pathways (ERPs). This study aimed to understand the perspectives of both healthcare professionals (HCPs) and patients on the locally studied acCelerated enHanced recovery After SurgEry (CHASE) protocol.

METHODS

For this mixed-method study, HCPs who provided CHASE care and patients who received CHASE care were recruited using purposive sampling. Ethical approval was obtained by the Medical Ethical Committee of the Zuyderland Medical Centre (NL71804.096.19, METCZ20190130, October 2022). Semi-structured, in-depth, one-on-one interviews were conducted with HCPs (n = 13) and patients (n = 11). The interviews consisted of a qualitative and quantitative part, the protocol evaluation and the Measurement Instrument or Determinant of Innovations-structured questionnaire. We explored the perspectives, barriers, and facilitators of the CHASE protocol implementation. The interviews were audiotaped, transcribed verbatim and analysed independently by two researchers using direct content analysis.

RESULTS

The results showed that overall, HCPs support the implementation of the CHASE protocol. The enablers were easy access to the protocol, the relevance of the intervention, and thorough patient education. Some of the reported barriers included the difficulty of recognizing CHASE patients, the need for regular feedback, and the updates on the implementation progress. Most patients were enthusiastic about early discharge after surgery and expressed satisfaction with the care they received. On the other hand, the patients sometimes received different information from different HCPs, considered the information to be too extensive and few experienced some discomfort with CHASE care.

CONCLUSION

Bringing CHASE care into practice was challenging and required adaptation from HCPs. The experiences of HCPs showed that the protocol can be improved further, and the mostly positive experiences of patients are a motivation for this improvement. These results yielded practical implications to improve the implementation of accelerated ERPs.

Perioperative nutritional assessment and management of patients undergoing gastrointestinal surgery

Malnutrition is a major issue in gastrointestinal perioperative situations, as only 40% of malnourished patients are finally treated. This literature review investigates the inconsistencies regarding the diagnostic approach to both preoperative and postoperative patients and the various underlying causes, as well as the efficiency of the various therapeutic regimens. A literature search was conducted until August 2023 in MEDLINE and Scopus. Clinical studies involving perioperative nutritional assessment in adult gastrointestinal surgery patients during the last 10 years were included in the present review. Finally, 19 articles were included in the study. Preoperative nutritional therapy is increasingly recognized as a key component of surgical care. Malnourished patients who are hospitalized and operated on, have significantly worse clinical results. Gastrointestinal postoperative malnutrition coexists with metabolic stress, as patients usually suffer from minor chronic inflammations; therefore, postoperative malnutrition is the result of a combination of the effects of inflammation and a lack of food intake. Postoperative malnutrition leads to prolonged hospitalizations and hospital complications and therefore the need to treat it is essential. There are many recognized tools for detecting malnutrition. However, all tools showed inconsistent results regarding their validity. Per os feeding after surgery, and dietary supplements when necessary, have been recommended. Therefore, it is very important to reduce malnutrition and define clear strategies towards that direction.

AI-powered real-time annotations during urologic surgery: The future of training and quality metrics

INTRODUCTION AND OBJECTIVE

Real-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time.

SUMMARY BACKGROUND DATA

While AI models possess the capability to generate automated annotations based on a collection of video images, the real-time implementation of such technology in urological robotic surgery to aid surgeon and training staff it is still pending to be studied.

METHODS

We conducted an educational symposium, which broadcasted 2 live procedures, a robotic-assisted radical prostatectomy (RARP) and a robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones. This was achieved through trained algorithms, conventional video recognition, and novel Video Transfer Network technology which captures clips in full context, enabling automatic recognition and surgical mapping in real-time.

RESULTS

Real-time AI annotations for procedure #1, RARP, are found in Table 1. The safety milestone annotations included the apical safety maneuver and deliberate views of structures such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound, temporary clip application and removal, hemostatic powder application, and notable hemorrhage.

CONCLUSIONS

For the first time, surgical intelligence successfully showcased real-time AI annotations of 2 separate urologic robotic procedures during a live telecast. These annotations may provide the technological framework for send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support, leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes, and support training and education.

Fasting Versus a Heart-Healthy Diet Before Cardiac Catheterization: A Randomized Controlled Trial

BACKGROUND

Patients undergoing cardiac catheterization are ordered to take nothing by mouth after midnight before their procedure with no evidence to support this practice.

OBJECTIVE

To identify best practice for fasting requirements before cardiac catheterization through comparative evaluation in a prospective randomized controlled study.

METHODS

The study included a convenience sample of 197 patients undergoing elective cardiac catheterization in a progressive inpatient cardiac unit at a regional heart institute in the midwestern United States. The patients were randomized into 2 groups. Patients in the heart-healthy diet group could eat a specified diet with low-acid options until the scheduled procedure. Patients in the fasting group were restricted to nothing by mouth after midnight except for sips of water with medications until the scheduled procedure. Outcome measures included patient-reported satisfaction and complications.

RESULTS

Compared with patients in the fasting group, those in the heart-healthy diet group had significantly more satisfaction with the preprocedural diet. Patients in the heart-healthy diet group had less thirst and hunger before and after the procedure. No patients experienced pneumonia, aspiration, intubation, or hypoglycemia after the procedure. Fatigue, glucose level, gastrointestinal issues, and loading dose of antiplatelet medication did not differ between the groups.

CONCLUSIONS

Allowing patients to eat before elective cardiac catheterization posed no safety risk and benefited patient satisfaction and overall care. The results of this study may help identify best practice for allowing patients to eat before elective procedures using conscious sedation.

An evaluation of the effectiveness and safety of the Enhanced Recovery After Surgery (ERAS) program for patients undergoing colorectal surgery: a meta-analysis of randomized controlled trials

Introduction

The Enhanced Recovery After Surgery (ERAS) protocol reduces surgery-related stress and hospital stays for complicated surgical patients. It speeds recovery, reduces readmissions, and lowers morbidity and mortality. However, the efficacy of ERAS in colorectal surgery is still debatable.

Aim

To evaluate the effectiveness and safety of the ERAS program for patients undergoing colorectal surgery.

Material and methods

PRISMA-compliant searches were performed on Medline, Embase, PubMed, the Web of Sciences, and the Cochrane Database up to March 2023. The included articles compared ERAS protocol results for colorectal surgery patients to those of conventional care. RevMan was used for the meta-analysis, and the Cochrane RoB Tool was used to assess the study quality.

Results

The meta-analysis included 12 randomized controlled trials with a total of 1920 participants. There were 880 individuals in ERAS care and 1002 in conventional care. Weighted mean difference: -1.07 days, 95% confidence interval (CI): -1.53 to -0.60, p = 0.00001), overall length of stay: -4.12 days, 95% CI: -5.86 to -2.38, p = 0.00001), and post-operative hospital stay: -1.91 days, 95% CI: -4.73 to -0.91, p = 0.00001). Readmissions were higher in the ERAS group than in the normal care group (odds ratio (OR) = 1.20, 95% CI: 0.82 to 1.75, p = 0.35). Post-operative complications were lower in the ERAS care group (OR = 0.42; 95% CI: 0.27 to 0.65, p < 0.0001) and SSIs (OR = 0.75; 95% CI 0.52 to 1.08, p = 0.00001) than in the routine care group.

Conclusions

Care provided in line with the ERAS protocol has been shown to be successful and beneficial for patients following colorectal surgery, because it minimizes post-operative problems and length of hospital stay, and improves outcomes.

Eliminating the routine use of postoperative drain placement in patients undergoing robotic-assisted radical cystectomy with intracorporeal urinary diversion

INTRODUCTION

Perioperative management of patients undergoing radical cystectomy and urinary diversion utilizing both open and minimally invasive techniques have routinely included the use of drains in the operative field. We herein demonstrate the safety of robotic-assisted radical cystectomy (RARC) without the routine use of postoperative drains.

METHODS

Patients who underwent drainless RARC with intracorporeal urinary diversion between 2017 and 2022 at our institution were reviewed. Baseline and clinical characteristics as well as perioperative and postoperative outcomes were analyzed. The primary study outcome was incidence of postoperative urinary leak or intra-abdominal infectious collections within 90 days of RARC. A univariate and multivariable logistic regression analysis was performed to determine associations between study variables and the primary outcome.

RESULTS

Of 381 patients, 298 (78.2%) were male and median age and BMI were 68 (63, 76) and 26.2 [23.0, 29.8], respectively. Overall 30 and 90-day complication rates were 39.6% and 50.4%, respectively. Twenty-one (5.5%) patients experienced a urine leak or intra-abdominal infectious collections. Sub-group analysis of patients who experienced the primary outcome demonstrated median postoperative day of presentation was day 19, and this group required 16 total additional procedures. On multivariable logistic regression analysis, only prior radiation therapy was associated with the development of the primary outcome of urinary leak or intra-abdominal infectious collection (odds ratio: 15.12, 95% confidence interval [1.52-156.8], p = 0.02).

CONCLUSION

Drainless RARC with totally intracorporeal urinary diversion achieved competitive perioperative and complications outcomes compared to prior open and robotic series. In the context of a larger enhanced recovery after surgery protocol in RARC patients, the routine use of drains may be safely omitted.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.

Enhanced Recovery After Surgery (ERAS) Protocols for Improving Outcomes for Patients Undergoing Major Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have gained recognition as a perioperative care approach for patients undergoing major colorectal surgery. This systematic review aims to evaluate the effects of ERAS protocols on outcomes in this patient population. A systematic search was conducted in PubMed, Cochrane Library, and Embase databases for studies published between January 2010 and September 2021. Inclusion criteria encompassed studies assessing the impact of ERAS protocols on patients undergoing major colorectal surgery. Data were extracted, and a qualitative synthesis of the included studies was performed. A total of 18 studies met the inclusion criteria. The implementation of ERAS protocols was associated with several positive outcomes. Compared to traditional care, ERAS protocols significantly reduced the length of hospital stay (mean difference [MD]: -1.64 days, 95% confidence interval [CI]: -2.21 to -1.08, p<0.00001), postoperative complications (odds ratio [OR]: 0.57, 95% CI: 0.46 to 0.71, p<0.00001), and readmission rates (OR: 0.57, 95% CI: 0.38 to 0.85, p=0.006). ERAS protocols also led to a shorter time to return of bowel function (MD: -0.74 days, 95% CI: -1.03 to -0.45, p<0.00001), time to first mobilization (MD: -0.55 days, 95% CI: -0.82 to -0.28, p<0.0001), and time to first oral intake (MD: -0.62 days, 95% CI: -0.95 to -0.28, p=0.0003). Additionally, patients reported higher satisfaction levels with the implementation of ERAS protocols (MD: 1.02, 95% CI: 0.19 to 1.86, p=0.02). This systematic review demonstrates that the implementation of ERAS protocols in major colorectal surgery is associated with improved outcomes. ERAS protocols lead to reduced hospital stays, lower postoperative complications, and decreased readmission rates. Furthermore, they facilitate faster recovery of bowel function, mobilization, and oral intake. Patients also express higher satisfaction levels with ERAS implementation. Healthcare providers should consider adopting ERAS protocols to optimize perioperative care in patients undergoing major colorectal surgery.

Pediatric Colonic Anastomosis: Can Method of Anastomosis and Wound Closure be of Help?

Background

Enhanced recovery after surgery (ERAS) protocols after colorectal surgery focused on reduced bowel preparation, standardized feeding schedule, earlier return of bowel function, and earlier resumption of normal activities. ERAS in pediatric surgical practice is not well established. The present study aims to present the results of two colonic anastomosis techniques of interrupted single-layered closure: Halsted (Horizontal Mattress) and Matheson (serosubmucosal or appositional extramucosal) along with two different methods of colostomy wound closure and their influence on the adoption of ERAS protocol of early feeding and early discharge.

Materials and Methods

This single institute-based randomized control study was conducted in a tertiary care facility in Kolkata for 2.4 years. Patients were chosen randomly for serosubmucosal (Group I) and full-thickness (Group II) anastomosis.

Results

Among total of 91 patients (Group I-43 and Group II-48), Return of bowel sounds and passage of bowel averaged 1.51 ± 0.51 and 1.91 ± 0.55 days in Group I and 1.91 ± 0.57 and 3.9 ± 0.66 days in Group II, respectively. Postoperative hospital stay averaged 5.88 ± 1.12 days in Group I and 8.9 ± 1.17 days in Group II. Overall 15 (16.48%) patients had complications among which SSI (Suprficial surgical site infection) and minor leaks (Group I-3 and 1 and Group II-5 and 3, respectively) which were treated conservatively (Clavien-Dindo Grade-I) and three major leaks under Group II requiring surgical intervention (Clavien-Dindo Grade-III).

Conclusion

This study concludes that the technique of colostomy closure in the form serosubmucosal closure helps in the implementation of ERAS protocol by producing early bowel movement, early initiation of food, and less postoperative complications.

Comparison of the Effects of Special Care Enhanced Recovery and Conventional Recovery Methods after Mini Omega Gastric Bypass

Background

Bariatric surgery is a surgical procedure for patients with extreme obesity. Enhanced Recovery after Surgery (ERAS) is a method that provides special peri- and post-operation care. Here, we aimed to compare the effects of ERAS and standard recovery cares.

Materials and Methods

This is a randomized clinical trial that was performed in 2020-2021 in Isfahan on 108 candidates for mini gastric bypass. Patients were then randomly divided into two equal groups receiving ERAS and standard recovery protocols. Patients were examined and visited after one month regarding the average number of hospitalization days, the average days required to return to normal activity or work, occurrence of pulmonary thromboemboli (PTE) and the rate of readmission.

Results

Patients that received ERAS had significantly lower frequencies of nausea and vomiting (P = 0.032). Patients that received ERAS had significantly lower hospitalization duration (P < 0.001) compared to controls. No other significant differences were observed between two groups regarding surgery complication, re-admission rate and occurrence of PTE (P > 0.99 for all).

Conclusion

Patients that received ERAS protocol after gastric bypass had significantly lower hospitalization duration and lower incidence of nausea and vomiting. They also had similar post-operative outcomes compared to the standard protocol.

Analgesic potential of transdermal nicotine patch in surgery: a systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

We aimed (1) to systematically review the efficacy of transdermal nicotine patches (NP) for postoperative analgesia, (2) to establish the current quality of evidence and assist clinical decision-making on the subject, and (3) to identify methodological limitations and the need for more well-designed studies.

MATERIALS AND METHODS

We searched six electronic databases, protocol records, and other sources without date or language restriction until March 2022. To develop the search strategy, we formulated a clinical question by using the PICOD method. Eligibility criteria included randomised placebo-controlled trials on the analgesic potential of NP for surgical procedures. This systematic review followed the PRISMA 2020 statement, and we registered the protocol in PROSPERO (#CRD42020205956).

RESULTS

We included 10 randomised placebo-controlled trials (535 patients). The NP administered before induction of anaesthesia and at beginning of surgery reduced the pain immediately after surgery (-0.38; 95% confidence interval [CI]: -0.73 to -0.02), and 6 h (-0.34; 95% CI: -0.68 to -0.01), 12 h (-0.43; 95% CI: -0.71 to -0.15) and 24 h (-0.35; 95%CI: -0.59 to -0.10) after surgery, compared with the placebo patch (PP) group. Sensitivity testing suggests that opioid use could underestimate NP analgesia. Late demand for the first analgesic and consumption of rescue analgesics tended to be lower in the NP group.

CONCLUSIONS

The current findings suggest, with low certainty of evidence, the analgesic potential of NP for surgical procedures.

CLINICAL RELEVANCE

Perioperative use of NP significantly improved postoperative pain, even when opioids were administered or prescribed. Nevertheless, the clinical relevance should be interpreted with caution, owing to the effect sizes of the summary measures and methodological issues. The analgesic potential of NP as an adjuvant therapy to regulate pain and acute inflammation may offer certain clinical advantages, thus warranting further investigation.

[Enteral nutrition in postoperative rehabilitation after reconstructive esophageal and gastric surgery]

OBJECTIVE

To investigate enteral nutrition as a component of postoperative rehabilitation after reconstructive esophageal and gastric surgeries.

MATERIAL AND METHODS

The study included 217 patients who underwent reconstructive esophageal and gastric surgeries between 2010 and 2020. In the main group (n=121), patients underwent postoperative enhanced recovery program (ERAS). Early enteral feeding including micro-jejunostomy and early oral feeding was essential for postoperative management. The control group included 96 patients who were treated in traditional fashion. The primary endpoint was length of hospital-stay (LOS) and ICU-stay. Restoration of gastrointestinal function (peristalsis, stool, oral nutrition), anastomotic leakage rate and other complications comprised secondary endpoints.

RESULTS

Both groups did not differ by sex, age, body mass index, diagnosis and comorbidities. There was significant reduction in postoperative LOS in the ERAS group (14 (12; 15.8) and 9 (6.3; 12) days, p<0.0001). In the same group, we observed less in ICU-stay (4.7 (3.6; 5.6) and to 3.5 (2; 4) days, p<0.001), earlier recovery of peristalsis and X-ray control of anastomosis in patients with and without anastomotic leakage. Incidence of respiratory complications was lower in the ERAS group (p=0.034). Overall postoperative morbidity and mortality were similar.

CONCLUSION

Early enteral and oral feeding after esophageal and gastric reconstructive surgery reduces hospital-stay and accelerates postoperative rehabilitation.

The impact of gum-chewing on postoperative ileus following gynecological cancer surgery: A systematic review and meta-analysis of randomized controlled trials

Objective

To assess the effect and safety of gum-chewing on the prevention of postoperative ileus after gynecological cancer surgery.

Methods

We conducted a systematic review of randomized controlled trials (RCTs) published between 2000 and 2022 in English and Chinese, using the EBSCO, Web of Science, Scopus, Cochrane Central Register of Controlled Trials (Cochrane database), PubMed, Medline (via Ovid), Chinese National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, and Wan Fang databases. A total of 837 studies were screened using Endnote software, and those that met the inclusion criteria were selected for analysis. The main outcome of interest was the incidence of postoperative ileus, and secondary outcomes included time to first flatus, time to first bowel movement, and length of hospital stay.

Results

Two authors extracted data and performed quality assessment independently. The review included six RCTs with a total of 669 patients. Compared with routine care, gum-chewing could significantly reduce the incidence of postoperative ileus (RR 0.46, 95% CI: 0.30, 0.72, P=0.0006), shorten the time to first flatus (WMD -9.58, 95% CI: -15.04, -4.12, P=0.0006), first bowel movement (WMD -11.31, 95% CI: -21.05, -1.56, P=0.02), and the length of hospital stay (WMD -1.53, 95% CI: -2.08, -0.98, P<0.00001).

Conclusions

Gum-chewing is associated with early recovery of gastrointestinal function after gynecological cancer surgery and may be an effective and harmless intervention to prevent postoperative ileus.

Systemaic review registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, identifier CRD42022384346.

Update on preoperative evaluation and optimisation

The patients presenting for surgery today often belong to the extremes of age, have multiple co-morbidities, and undergo complex surgeries. This makes them more prone to morbidity and mortality. A detailed preoperative evaluation of the patient can contribute to reducing this mortality and morbidity. There are various risk indices and validated scoring systems and many of them need to be calculated using preoperative parameters. Their key objective is to identify patients vulnerable to complications and to return them to desirable functional activity as soon as possible. Any individual undergoing surgery should be optimised preoperatively, but special considerations should be given to patients with comorbidity, on multiple drugs, and undergoing high-risk surgery. The objective of this review is to put forth the latest trends in the preoperative evaluation and optimisation of patients undergoing noncardiac surgery and emphasise the importance of risk stratification in these patients.

The importance of inflammatory markers in detection of complications in patients with gastric cancer undergoing the Enhanced Recovery After Surgery (ERAS) protocol: a prospective cohort study

Introduction

Early diagnosis reduces mortality and morbidity rates in gastrointestinal system (GIS) anastomoses.

Aim

The aim of the present study was to investigate the importance of some substances that were used to detect major complications early in patients who were treated in line with the Enhanced Recovery After Surgery (ERAS) protocol for gastric cancer. Factors included in the study were interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), procalcitonin (PCT) and white blood cell (WBC).

Material and methods

A hundred and twenty patients who underwent laparoscopic subtotal or total gastrectomy for gastric cancer in accordance with the ERAS protocol between January 2018 and December 2019 were included in this prospective study. Blood values of IL-1β, TNF-α, CRP, PCT, and WBC on the third and fifth post-operative days (POD) were measured for diagnosing major complications.

Results

Major complications occurred in 12 (10%) patients. Third POD and fifth POD measurements of IL-1β, TNF-α, CRP, PCT were statistically significantly higher than those in the non-complicated group, whereas WBC was not. In addition, in the group with complications, statistically significant changes of the blood levels of IL-1β, TNF-α, CRP, and PCT between the 3^rd and 5^th days were detected (p = 0.008, p = 0.001, p = 0.004, p = 0.001 respectively).

Conclusions

IL-1β, TNF-α, CRP, and PCT can be used in the early detection of major complications in gastric cancer patients undergoing the ERAS protocol. Imaging methods should be used in patients with high levels of these inflammatory substances on the third and fifth POD.

Preoperative carbohydrate loading before colorectal surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Preoperative carbohydrate loading has been introduced as a component of many enhanced recovery after surgery programs. Evaluation of current evidence for preoperative carbohydrate loading in colorectal surgery has never been synthesized.

METHODS

MEDLINE, Embase, and CENTRAL were searched until May 2021. Randomized controlled trials (RCTs) comparing patients undergoing colorectal surgery with and without preoperative carbohydrate loading were included. Primary outcomes were changes in blood insulin and glucose levels. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

The search yielded 3656 citations, from which 12 RCTs were included. In total, 387 patients given preoperative carbohydrate loading (47.2% female, age: 62.0 years) and 371 patients in control groups (49.4% female, age: 61.1 years) were included. There was no statistical difference for blood glucose and insulin levels between both patient groups. Patients receiving preoperative carbohydrate loading experienced a shorter time to first flatus (SMD: - 0.48 days, 95% CI: - 0.84 to - 0.12, p = 0.008) and stool (SMD: - 0.50 days, 95% CI: - 0.86 to - 0.14, p = 0.007). Additionally, length of stay was shorter in the preoperative carbohydrate loading group (SMD: - 0.51 days, 95% CI: - 0.88 to - 0.14, p = 0.007). There was no difference in postoperative morbidity and patient well-being between both groups.

CONCLUSIONS

Preoperative carbohydrate loading does not significantly impact postoperative glycemic control in patients undergoing colorectal surgery; however, it may be associated with a shorter length of stay and faster return of bowel function. It merits consideration for inclusion within colorectal enhanced recovery after surgery protocols.

Identification of risk factors and clinical model construction of abdominal distension after radical cystectomy

Background

The occurrence of abdominal distention after radical cystectomy (RC) is common. We sought to determine risk factors of abdominal distention after RC, and to establish a simple and reliable nomogram for clinical risk assessment.

Methods

Clinical information on 139 patients who underwent RC from January 2020 to August 2021 was collected. The chi-square test, hypergeometric test, and univariate/multivariate logistic regression were utilized to explore the relationship between variables and abdominal distention after RC. A nomogram was then used to predict the probability of abdominal distension for the patients who underwent RC. Calibration and receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the model.

Results

We found that 35 patients (25%) occurred in abdominal distention after RC. Among the patients, 7 of them developed intestinal obstruction. Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. Finally, we constructed a risk model to predict the probability of abdominal distension after surgery. This model showed good fitting and calibration and excellent diagnostic performance with an area under the curve (AUC) of 0.804.

Conclusions

Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. There was no significant difference in the incidence of postoperative abdominal distention between robot-assisted cystectomy and laparoscopic cystectomy.

Efficacy and safety of pre-gastroscopy commercial carbohydrate-rich whey protein beverage vs. plain water: a randomised controlled trial

Clinical benefits and safety of carbohydrate loading pre-gastroscopy remain unclear. We aimed to determine the effects of a commercial carbohydrate-rich whey protein beverage versus plain water given pre-gastroscopy on gastric residual volume and well-being, and to determine adverse events. This was a single centre, single-blinded, parallel-group, sex-stratified randomized controlled trial. Participants were randomized either to carbohydrate-rich whey protein beverage group (Resource®, Nestle Health Science) or control group (250 ml plain water) given pre-gastroscopy. Gastric contents were aspirated into a suction reservoir bottle to determine the gastric residual volume (GRV). Visual analogue scale (VAS) of well-being (anxiety, hunger, thirst, tiredness, and weakness) was compared before and after the intervention. Adverse events were also evaluated post-intervention. Of 369 screened, 78 participants (36 males, mean age 49 ± 14.3 years) were randomized. Compared with the control group, carbohydrate beverage was associated with significantly higher GRV (p < 0.001). Anxiety was less after intervention with carbohydrate beverage (p = 0.016), and after adjustment for confounders, fewer participants also experienced hunger (p = 0.043) and thirst (p = 0.021). No serious adverse events were reported with both interventions. Commercial carbohydrate-rich whey protein beverage is associated with higher gastric residual volume, better well-being and safe.Trial registration Clinicaltrial.gov. Identifier: NCT03948594, Date of registration: 14/05/2019.

Evaluation of preoperative duloxetine use for postoperative analgesia following laparoscopic cholecystectomy: A randomized controlled trial

Background: The pain pattern after laparoscopic cholecystectomy (LC) is complex and distinct from postoperative pain after other laparoscopic procedures, suggesting that procedure-specific optimal analgesic management plans should be proposed. Duloxetine, a non-opioid neuromodulator, has been widely used to manage pain with dual central and peripheral analgesic properties.

Aims: To assess the effect of preoperative administration of duloxetine compared to placebo on postoperative pain control in patients undergoing LC.

Patients and Methods: This study was a randomized, parallel-group, placebo-controlled, double-blinded study performed on patients undergoing LC. Patients were randomly divided into two groups of 30 each on the day of surgery in the preoperative holding area, using a computer-generated random number to receive 60 mg duloxetine as a single oral dose 2 h before the procedure or placebo. The primary outcome was the difference in the mean of visual analogue scale (VAS) scores between the two studied groups, as measured by the area under the curve (AUC) of the VAS scores.

Results: The derived AUC of VAS scores in the duloxetine group (757.89 ± 326.01 mm × h) was significantly lower than that calculated for the control group (1005.1 ± 432.5 mm × h). The mean postoperative VAS scores recorded at 4 and 24 h were statistically different between the study groups (p = 0.041 and 0.003, respectively). As observed in the survival curve analysis, there was no significant difference (p = 0.665) for the time until the patient’s first request for rescue medications in the two groups. The frequency of postoperative nausea and vomiting (PONV) was lower in patients of the duloxetine group than that recorded in those allocated to the control group at 8 and 24-h time intervals (p = 0.734 and 0.572, respectively).

Conclusion: Preoperative use of duloxetine reduces postoperative pain significantly compared with placebo. In addition, its use is associated with a reduction in PONV. These preliminary findings suggest that duloxetine could play a role in the acute preoperative period for patients undergoing LC.

Clinical Trial Registration: [https://clinicaltrials.gov/ct2/show/NCT05115123, identifier NCT05115123],

Clinical practice recommendations for prehabilitation and post-operative rehabilitation for arthroplasty: A scoping review

BACKGROUND

The rising need for arthroplasty (joint replacement) has resulted in a significant increase in wait-times. Longer surgical wait-times may further exacerbate functional decline in adults with osteoarthritis as well as delay postoperative functional recovery. This review aims to better inform rehabilitation care provision before (prehabilitation) and after (post-rehabilitation) hip or knee arthroplasty based on recommendations from clinical practice guidelines (CPGs).

METHODS

This scoping review used a three-stage process to screen and extract articles, which resulted in 123 articles reviewed for analysis. Included CPGs were in the English language and focussed on rehabilitation interventions or practices involving adult patients preparing for or recuperating from hip and knee arthroplasty (published 2009-2020).

RESULTS

Patient assessments, use of assistive devices, as well as self-management and education programs were recommended before and after arthroplasty. Physiotherapy was recommended to support post-operative rehabilitation. Conversely, there was limited evidence supporting recommendations for or against physiotherapy during the prehabilitation phase of the arthroplasty care journey.

CONCLUSIONS

The findings from this review highlight the current gap in high-quality evidence supporting hip and knee arthroplasty rehabilitation CPGs before and after surgery. Findings warrant additional research to ensure patients are best prepared for surgery and supported for optimal recovery.

Effectiveness of Preoperative Chest Physiotherapy in Patients Undergoing Elective Cardiac Surgery, a Systematic Review and Meta-Analysis

Background and Objectives: Patients undergoing cardiac surgery are particularly vulnerable for developing postoperative pulmonary complications (PPCs). This systematic review and meta-analysis aimed to evaluate the role of preoperative chest physiotherapy in such patients. Materials and Methods: All original articles that assessed patients undergoing elective cardiac surgery, with preoperative chest physiotherapy, and compared them to patients undergoing elective cardiac surgery, without preoperative chest physiotherapy, were included. Animal studies, studies conducted prior to the year 2000, commentaries, or general discussion papers whose authors did not present original data were excluded. Studies assessing physiotherapy regimens other than chest physiotherapy were also excluded. The search was performed using the following electronic resources: the Cochrane Central Register of Controlled Trials, the PubMed central database, and Embase. The included studies were assessed for potential bias using the Cochrane Collaboration’s tool for assessing the risk of bias. Each article was read carefully, and any relevant data were extracted. The extracted data were registered, tabulated, and analyzed using Review Manager software. Results: A total of 10 articles investigating 1458 patients were included in the study. The studies were published from 2006 to 2019. The populations were patients scheduled for elective CABG/cardiac surgery, and they were classified into two groups: the interventional (I) group, involving 651 patients, and the control (C) group, involving 807 patients. The meta-analysis demonstrated no significant differences between the interventional and control groups in surgery time and ICU duration, but a significant difference was found in the time of mechanical ventilation and the length of hospital stay, favoring the interventional group. A significant difference was shown in the forced expiratory volume in 1s (FEV1% _predicted), forced vital capacity (FVC% _predicted), and maximum inspiratory pressure (Pi-max), favoring the interventional group. Conclusions: This study is limited by the fact that one of the included ten studies was not an RCT. Moreover, due to lack of the assessment of certain variables in some studies, the highest number of studies included in a meta-analysis was the hospital stay length (eight studies), and the other variables were analyzed in a fewer number of studies. The data obtained can be considered as initial results until more inclusive RCTs are conducted involving a larger meta-analysis. However, in the present study, the intervention was proved to be protective against the occurrence of PPCs. The current work concluded that preoperative chest physiotherapy can yield better outcomes in patients undergoing elective cardiac surgery.

A systematic review of the impact of post-operative oral fluid intake on ileus following elective colorectal surgery

INTRODUCTION

Ileus (delayed return of bowel function after surgery) is one of the highest priority research questions in modern day colorectal practice. Current Enhanced Recovery After Surgery (ERAS) guidance either does not include a specific recommendation for volume of postoperative oral fluids/foodstuffs or suggests ad-lib fluids. It is unclear if the volume of intake affects ileus rates. This systematic review aimed to determine the optimal fluid volume for patients to consume day one after elective colorectal surgery.

METHODS

The literature was searched across seven databases, 23/09/2020. Randomised controlled trials of adults undergoing elective colorectal surgery, comparing oral intake postoperatively were eligible for inclusion. Two blinded reviewers assessed papers with disagreements resolved by a third independent reviewer. Main outcomes were resolution of postoperative ileus and length of hospital stay. Secondary outcomes included vomiting, mortality and complications.

RESULTS

Of 2175 screened papers, eight were eligible for inclusion. All studies gave a clear liquid diet postoperatively. The comparison groups followed a traditional nil-by-mouth approach. All studies showed a minor reduction in postoperative ileus and hospital stay in the intervention group, but we are unable to determine the optimal postoperative oral fluid volume. The low number and poor quality of studies was a significant limitation. None of the trials were conducted within an ERAS protocol: only 883 patients were included in total.

CONCLUSIONS

From the current literature it is unclear how postoperative oral fluid volume intake affects gastrointestinal function and ileus in elective colorectal surgical patients. This remains an important area for further research.