Immediate mobilization in post-anesthesia care unit does not increase overall postoperative physical activity after elective colorectal surgery: A randomized, double-blinded controlled trial within an enhanced recovery protocol

BACKGROUND

The level of post-operative mobilization according to Enhanced Recovery After Surgery (ERAS) guidelines is not always achieved. We investigated whether immediate mobilization increases postoperative physical activity. The objective was to evaluate the effects of immediate postoperative mobilization in the post-anesthesia care unit (PACU) compared to standard care.

METHODS

This randomized controlled trial, involved 144 patients, age ≥18 years, undergoing elective colorectal surgery. Patients were randomized to mobilization starting 30 min after arrival in the PACU, or to standard care. Standard care consisted of mobilization a few hours later at the ward according to ERAS guidelines. The primary outcome was physical activity, in terms of number of steps, measured with an accelerometer during postoperative days (PODs) 1-3. Secondary outcomes were physical capacity, functional mobility, time to readiness for discharge, complications, compliance with the ERAS protocol, and physical activity 1 month after surgery.

RESULTS

With the intention-to-treat analysis of 144 participants (median age 71, 58% female) 47% underwent laparoscopic-or robotic-assisted surgery. No differences in physical activity during hospital stay were found between the participants in the intervention group compared to the standard care group (adjusted mean ratio 0.97 on POD 1 [95% CI, 0.75-1.27], p = 0.84; 0.89 on POD 2 [95% CI, 0.68-1.16], p = 0.39, and 0.90 on POD 3 [95% CI, 0.69-1.17], p = 0.44); no differences were found in any of the other outcome measures.

CONCLUSIONS

Addition of the intervention of immediate mobilization to standard care did not make the patients more physically active during their hospital stay.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NTC 03357497.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

A survey of preoperative surgical nutrition practices, opinions, and barriers across Canada

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n = 111 dietitians, n = 72 physicians, n = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period (n = 117) by dietitians (n = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n = 121/212), time (40%, n = 84/212) and support from others (38%, n = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.

Altered insulin sensitivity and immune function in patients with colorectal cancer

BACKGROUND & AIMS

Insulin resistance and chronic inflammation have been reported in patients with cancer. However, many of the underlying mechanisms and associations are yet to be unveiled. We examined both the level of insulin sensitivity and markers of inflammation in patients with colorectal cancer for comparison to controls.

METHODS

Clinical exploratory study of patients with colorectal cancer (n = 20) and matched controls (n = 10). Insulin sensitivity was quantified using the hyperinsulinemic normoglycemic clamp and blood samples were taken for quantification of several key, both intra- and extracellular, inflammatory markers. We analysed the differences in these parameters between the two groups.

RESULTS

Patients exhibited both insulin resistance (M-value, patients median (Mdn) 4.57 interquartile range (IQR) 3.49-5.75; controls Mdn 5.79 (IQR 5.20-6.81), p = 0.049), as well as increased plasma levels of the pro-inflammatory cytokines IL-1β (patients Mdn 0.48 (IQR 0.33-0.58); controls Mdn 0.36 (IQR 0.29-0.42), p = 0.02) and IL-6 (patients Mdn 3.21 (IQR 2.31-4.93); controls Mdn 2.16 (IQR 1.50-2.65), p = 0.02). The latter is present despite an almost two to three fold decrease (p < 0.01) in caspase-1 activity, a facilitating enzyme of IL-1β production, within circulating immune cells.

CONCLUSION

Patients with colorectal cancer displayed insulin resistance and higher levels of plasma IL-1β and IL-6, in comparison to matched healthy controls. The finding of a seemingly disconnect between inflammasome (caspase-1) activity and plasma levels of key pro-inflammatory cytokines in cancer patients may suggest that, in parallel to dysregulated immune cells, tumour-driven inflammatory pathways also are in effect.

Ferric derisomaltose and Outcomes in the Recovery of Gynecologic oncology: ERAS (Enhanced Recovery After Surgery) (FORGE) - a protocol for a pilot randomised double-blinded parallel-group placebo-controlled study of the feasibility and efficacy of intravenous ferric derisomaltose to correct preoperative iron-deficiency anaemia in patients undergoing gynaecological oncology surgery

INTRODUCTION

Iron-deficiency anaemia is common in gynaecological oncology patients. Blood transfusions are immunosuppressive and carry immediate and long-term risks. Oral iron replacement remains the standard of care but requires prolonged treatment courses associated with gastrointestinal side effects, poor compliance and variable absorption in cancer patients. Intravenous iron has been shown to decrease the need for allogeneic blood transfusion in gynaecological oncology patients undergoing chemotherapy, but the efficacy of this treatment in the preoperative period is unknown. The goal of this pilot study is to determine the effect of intravenous ferric derisomaltose on preoperative haemoglobin in patients undergoing surgery for gynaecological malignancy.

METHODS AND ANALYSIS

We will conduct a pilot single-centre, parallel-arm randomised controlled trial of intravenous ferric derisomaltose versus placebo among consenting patients with iron-deficiency anaemia having elective major surgery on the gynaecological oncology service. Patients, clinicians and outcome assessors will be blinded. The intervention consists of a single infusion of 500-1000 mg of intravenous ferric derisomaltose administered a minimum of 21 days prior to the planned operation. The primary outcome is mean preoperative haemoglobin concentration measured 0-3 days prior to surgery in patients receiving intravenous ferric derisomaltose compared with those receiving placebo. Secondary outcomes include the following: change in haemoglobin concentration, postoperative haemoglobin concentration, perioperative blood transfusion rates, patient-reported quality of life scores (Quality of Recovery 15, Modified Short Form 36 v1, EuroQol 5-dimension 5-level and Functional Assessment of Cancer Therapy - Anaemia), surgical site infection, complication rates, length of hospital stay and readmission rate. Analyses will follow intention-to-treat principles for all randomised participants. All patients will be followed up to 60 days following surgery.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Health Research Ethics Board of Alberta (Project ID: HREBA.CC-22-0187) and Health Canada (HC6-024-c264013). Results will be disseminated through presentation at scientific conferences, peer-reviewed publication and social and traditional media.

TRIAL REGISTRATION NUMBER

NCT05407987.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS^® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS^® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS^® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Enhanced Recovery After Surgery and Elderly Patients

Enhanced recovery after surgery (ERAS) is a new way of working where evidence-based care elements are assembled to form a care pathway involving the patient's entire journey through surgery. Many elements included in ERAS have stress-reducing effects on the body or helps avoid side effects associated with alternative treatment options. This leads to less overall stress from the injury caused by the operation and helps facilitate recovery. In old, frail patients with concomitant diseases and less physical reserves, this may help explain why the ERAS care is reported to be beneficial for this specific patient group.

Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process

IMPORTANCE

Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively.

OBJECTIVE

To integrate the 2 tools to facilitate key perioperative decision-making.

EVIDENCE REVIEW

Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022.

FINDINGS

Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs.

CONCLUSIONS AND RELEVANCE

The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

Background

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care.

Methods

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus.

Results

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

Conclusions

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Prehabilitation, enhanced recovery after surgery, or both? A narrative review

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.

Patients' perspectives of prehabilitation as an extension of Enhanced Recovery After Surgery protocols

Background:

Enhanced Recovery After Surgery (ERAS) and prehabilitation programs are evidence-based and patient-focused, yet meaningful patient input could further enhance these interventions to produce superior patient outcomes and patient experiences. We conducted a qualitative study with patients who had undergone colorectal surgery under ERAS care to determine how they prepared for surgery, their views on prehabilitation and how prehabilitation could be delivered to best meet patient needs.

Methods:

We conducted semistructured interviews with adult patients who had undergone colorectal surgery under ERAS care within 3 months after surgery. Patients were enrolled between April 2018 and June 2019 through purposive sampling from 1 hospital in Alberta. The interview transcripts were analyzed independently by a researcher and a trained patient-researcher using inductive thematic analysis.

Results:

Twenty patients were interviewed. Three main themes were identified. First, waiting for surgery: patients described fear, anxiety, isolation and deterioration of their mental and physical states as they waited passively for surgery. Second, preparing would have been better than just waiting: patients perceived that a prehabilitation program could prepare them for their operation if it addressed their emotional and physical needs, provided personalized support, offered home strategies, involved family and included surgical expectations (both what to expect and what is expected of them). Third, partnering with patients: preoperative preparation should occur on a continuum that meets patients where they are at and in a partnership that respects patients’ expertise and desired level of engagement.

Conclusion:

We identified several patient priorities for the preoperative period. Integrating these priorities within ERAS and prehabilitative programs could improve patient satisfaction, experiences and outcomes. Actively engaging patients in their care might alleviate some of the anxiety and fear associated with waiting passively for surgery.

Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study

BACKGROUND

Early mobilization is a significant part of the ERAS^® Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach.

METHODS

This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space.

RESULTS

In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred.

CONCLUSIONS

Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery. Trial registration Clinical trials.gov identifier: NTC03357497.

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

BACKGROUND

We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS).

METHODS

This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI.

RESULTS

A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10 µmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63-11.70; P < 0.001).

CONCLUSIONS

Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity?

PURPOSE OF REVIEW

A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation.

RECENT FINDINGS

All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening.

SUMMARY

There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Importance

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations

Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions and Relevance

To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

The effect of glucose control in liver surgery on glucose kinetics and insulin resistance

BACKGROUND & AIMS

Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied.

METHODS

18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n = 9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 9) received insulin if blood glucose >11.5 mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery.

RESULTS

Mean intraoperative glucose was 7.0 mM (SD 0.7) vs 9.1 mM (SD 1.9) in the insulin and control group respectively (p < 0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p = 0.03, ANOVA) more in the control group (M value: 4.6 (4.4-6.8) to 2.1 (1.2-2.6) and 4.6 (4.1-5.0) to 0.6 (0.1-1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p = 0.02) while WGD remained unchanged (p = 0.67).

CONCLUSION

Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered.

REGISTRATION NUMBER OF CLINICAL TRIAL

ANZCTR 12614000278639.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

METHODS

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

RESULTS

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

CONCLUSIONS

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Short-term outcome in robotic vs laparoscopic and open rectal tumor surgery within an ERAS protocol: a retrospective cohort study from the Swedish ERAS database

BACKGROUND

Advantages of robotic technique over laparoscopic technique in rectal tumor surgery have yet to be proven. Large multicenter, register-based cohort studies within an optimized perioperative care protocol are lacking. The aim of this retrospective cohort study was to compare short-term outcomes in robotic, laparoscopic and open rectal tumor resections, while also determining compliance to the enhanced recovery after surgery (ERAS)®Society Guidelines.

METHODS

All patients scheduled for rectal tumor resection and consecutively recorded in the Swedish part of the international ERAS® Interactive Audit System between January 1, 2010 to February 27, 2020, were included (N = 3125). Primary outcomes were postoperative complications and length of stay (LOS) and secondary outcomes compliance to the ERAS protocol, conversion to open surgery, symptoms delaying discharge and reoperations. Uni- and multivariate comparisons were used.

RESULTS

Robotic surgery (N = 827) had a similar rate of postoperative complications (Clavien-Dindo grades 1-5), 35.9% compared to open surgery (N = 1429) 40.9% (OR 1.15, 95% CI (0.93, 1.41)) and laparoscopic surgery (N = 869) 31.2% (OR 0.88, 95% CI (0.71, 1.08)). LOS was longer in the open group, median 9 days (IRR 1.35, 95% CI (1.27, 1.44)) and laparoscopic group, 7 days (IRR 1.14, 95% CI (1.07, 1.21)) compared to the robotic group, 6 days. Pre- and intraoperative compliance to the ERAS protocol were similar between groups.

CONCLUSIONS

In this multicenter cohort study, robotic surgery was associated with shorter LOS compared to both laparoscopic and open surgery and had lower conversion rates vs laparoscopic surgery. The rate of complications was similar between groups.

Validity of Routinely Collected Swedish Data in the International Enhanced Recovery After Surgery (ERAS) Database

Background

This study aims to assess patient coverage, validity and data quality in the Swedish part of the International Enhanced Recovery After Surgery (ERAS) Interactive Audit System (EIAS).

Method

All Swedish ERAS centers that recorded colorectal surgery data in EIAS between January 1, 2017, and December 31, 2017, were included (N = 12). Information registered in EIAS was compared with data from electronic medical records at each hospital to assess the overall coverage of EIAS. Twenty random-selected patients from each of the contributing centers were assessed for accuracy for a set of clinically relevant variables. All patients admitted to the contributing centers were included for the assessment of rate of missing on a selection of key clinical variables.

Results

Eight hospitals provided complete information for the evaluation, while four hospitals only allowed assessment of coverage and missing data. The eight hospitals had an overall coverage of 98.8% in EIAS (n = 1301) and the four 86.7% (n = 811). The average agreement for the assessed postoperative outcome variables was 96.5%. The accuracy was excellent for ‘length of hospital stay,’ ‘reoperation,’ and ‘any complications,’ but lower for other types of complications. Only a few variables had more than 5% missing data, and missingness was associated with hospital type and size.

Conclusion

This validation of the Swedish part of the international ERAS database suggests high patient coverage in EIAS and high agreement and limited missingness in clinically relevant variables. This validation approach or a modified version can be used for continued validation of the International ERAS database.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06094-4.

Requirements for a successful Enhanced Recovery After Surgery (ERAS) program: a multicenter international survey among ERAS nurses

Introduction

Nurses are the linchpin of any Enhanced Recovery After Surgery (ERAS) program, as they are in direct contact with patients and various caregivers. The aim of the present survey was to assess ERAS key factors and challenges from a nurse’s perspective.

Methods

A qualitative study among ERAS dedicated nurses and ERAS Interactive Audit System (EIAS) administrators using an online questionnaire (Survey Monkey®, Palo Alto, CA, United States) comprising 29 questions. The survey focused on challenges and drawbacks encountered during ERAS training, implementation and daily clinical practice. Closed multiple-choice and open-end questions and semantic differential scales (0–10) were used. Those invited to participate received three reminders within 4 and 8 weeks after invitation.

Results

Of 306 nurses invited, 123 completed the survey (response rate 40%). Overall, the success of the institutional ERAS program was rated as 6.9 ± 2/10. Improving both patient outcomes (90%) and satisfaction (69%) were rated as main motivators for ERAS implementation, while time restraints (50%) and logistics (43%) were identified as the main barriers. The study revealed a wide heterogeneity in coordination and management strategies (ERAS meetings, work models, teaching strategies). Sustained staff education before (9.1/10) and after (9.1/10) implementation, a dedicated ERAS coordinator (8.9/10) and regular meetings (8.3/10 scale) were rated as key factors for a successful program. Difficulty of implementation, maintenance and data acquisition were all rated > 5/10.

Conclusion

Despite heterogeneity in coordination and management, the ERAS program is evaluated as successful from a nurse’s perspective. Continuous staff education and coordination beyond the implementation period appear to be of the utmost importance for a sustained program.

Perioperative nutrition: Recommendations from the ESPEN expert group

BACKGROUND & AIMS

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

METHODS

This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

RESULTS

Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

CONCLUSIONS

Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study

RATIONALE

Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients.

METHODS

160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups.

RESULTS

Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups.

CONCLUSION

Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.

Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study

OBJECTIVE

Colon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

This is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality.

RESULTS

The study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001).

CONCLUSION

Preoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.

The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America

The shortage of hospital beds and changes in the payment model have promoted an increased attention and financing of programs that focus on perioperative care efficiency in. Latin America. In this paper, Enhanced Recovery After Surgery (ERAS) programs developed by the ERAS® Society will be discussed. The implementation and use of ERAS®Society Guidelines consistently demonstrated a reduction in postoperative complications, hospital stay and costs. In the current paper, the definition of ERAS programs, their core elements, and the results of their implementation and regional developments are presented with special focus on Latin America.

Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines

BACKGROUND

ERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development.

METHODS

The ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence.

RESULTS

Clear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus-based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up-to-date evidence is used consistently to support surgical patients.

CONCLUSION

There is a need for a standardized, evidence-informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners

Background

Pulmonary aspiration of gastric contents is recognized as a complication of anesthesia. To minimize that risk, anesthesiologists advised fasting for solid foods and liquids for an often prolonged period of time. However, 30 years ago, evidence was promulgated that fasting for clear liquids was unnecessary to ensure an empty stomach. Despite a strong evidence base and the knowledge that fasting may be physiologically harmful and unpleasant for patients, the adoption of society guidelines recommending short fasting periods for clear fluids into clinical practice is uncertain.

Objective

This study aimed to determine the current practices of anesthetists with respect to fasting guidelines.

Methods

An electronic internet survey was distributed to anesthetists in Canada (CAN), Australia and New Zealand (ANZ), and Europe (EUR) during April 2014 to February 2015. The anesthetists were asked about fasting guidelines, their recommendations to patients for the consumption of clear fluids and solid foods, and the reasons and consequences if these guidelines were not followed.

Results

A total of 971 anesthetists completed the survey (CAN, n=679; ANZ, n=185; and EUR, n=107). Although 85.0% (818/962) of these participants claimed that their advice to patients followed current society guidelines, approximately 50.4% (476/945) enforced strict fasting and did not allow clear fluids after midnight. The primary reasons given were with regard to problems with a variable operating room schedule (255/476, 53.6%) and safety issues surrounding the implementation of clear fluid drinking guidelines (182/476, 38.2%).

Conclusions

Many anesthetists continue to follow outdated practices. The current interest in further liberalizing preoperative fluid intake will require more change in anesthesia culture.

Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer

INTRODUCTION

Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results.

OBJECTIVE

The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer.

MATERIAL AND METHODOLOGY

Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan-Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), < 80% adherence, and Group 2 (241 patients), ≥ 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters.

RESULTS

The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61-6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19-5.52, p = 0.0161), and compliance with ERAS protocol < 80% (HR 3.38, 95% CI 2.23-5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p < 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p < 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p < 0.0001) and mobilization (77.7% vs. 96.1%, p < 0.0001) on the first postoperative day.

CONCLUSIONS AND RELEVANCE

This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates.

The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer

BACKGROUND

Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.

STUDY DESIGN

This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.

RESULTS

A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055).

CONCLUSION

The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.