Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials

Decreasing Opioid Usage in Pediatric Cholecystectomy Through Care Standardization: A Quality Improvement Project Using Enhanced Recovery After Surgery Protocols

BACKGROUND

While enhanced recovery after surgery protocols have been successful in adults, their impact in pediatric surgery is less documented.

SMART AIM

Reduce opioid use in morphine milligram equivalents by 25% over 32 months through an enhanced recovery after surgery protocol. This period included 5 months dedicated to testing and implementing the protocol, followed by 27 months of full implementation. Process measures ensured adherence, with 30-day readmission rates, pain scores, postoperative nausea and vomiting, pruritus, and hospital length of stay as balancing measures.

METHODS

Inconsistent perioperative management led to variable opioid use in pediatric laparoscopic cholecystectomy patients at our hospital. A quality improvement project using the Model for Improvement was implemented at a 443-bed pediatric academic hospital. A multidisciplinary enhanced recovery after surgery team implemented perioperative standardizations supported by electronic medical record best practice advisories, monthly educational sessions, and stakeholder engagement.

RESULTS

After full enhanced recovery after surgery protocol implementation, morphine milligram equivalents decreased by 27% over 32 months. Mean pain scores decreased from 4.69 (95% CI: 4.32-5.06) pre-enhanced recovery after surgery to 4.10 (95% CI: 3.84-4.36) post-enhanced recovery after surgery. Postoperative nausea and vomiting incidence decreased from 18% (95% CI: 11.7-26.7) to 15% (95% CI: 9.3-23.3), and pruritus incidence declined from 6% (95% CI: 2.8-12.5) to 5% (95% CI: 2.2-11.2). Mean hospital length of stay was 1.37 days (95% CI: 1.33-1.41) pre-enhanced recovery after surgery and 1.34 days (95% CI: 1.30-1.38) post-enhanced recovery after surgery. The 30-day readmission rate remained unchanged, with the sole readmission attributed to constipation.

CONCLUSION

Standardizing care through enhanced recovery after surgery protocols effectively reduces opioid use in pediatric laparoscopic cholecystectomy without increasing mean postoperative pain scores, postoperative nausea and vomiting, pruritus, or hospital length of stay.

Association of Socioeconomic Disadvantage With Postoperative Length of Stay

INTRODUCTION

Socioeconomic factors significantly influence postoperative recovery, which is a crucial consideration in reducing disparities within enhanced recovery after surgery (ERAS) protocols. The Area Deprivation Index (ADI) serves as a validated measure of neighborhood-level socioeconomic disadvantage; however, its association on postoperative length of stay (LOS) remains underexplored.

METHODS

This retrospective cohort study analyzed data from October 2016 to May 2022, examining the association between ADI and postoperative LOS among ERAS patients undergoing elective surgery. Addresses were geocoded and assigned ADI scores, categorizing patients into low, medium, and high ADI levels. Logistic regression models, adjusting for covariates such as insurance status and comorbidities, were used to assess the relationship between ADI and extended LOS, defined as above the 75th percentile.

RESULTS

The study included 11,640 patients with a median age of 56. Patients from high ADI neighborhoods had a significantly higher likelihood of extended LOS compared to those from low ADI neighborhoods (odds ratio 1.22; 95% confidence interval 1.10-1.36; P < 0.001), even after adjusting for demographic and clinical factors.

CONCLUSIONS

Higher socioeconomic disadvantage, as measured by ADI, is associated with prolonged postoperative hospital stays. These findings highlight the need for targeted interventions to mitigate disparities in surgical outcomes and enhance equity in ERAS protocols.

Multimodal Prehabilitation in Major Abdominal Surgery-Rationale, Modalities, Results and Limitations

Recent evidence revealed that an adequate preoperative physiological reserve is crucial to overcome surgical stress response. Consequently, a new concept, called prehabilitation, emerged, aiming to improve the preoperative functional reserve of patients who will undergo major abdominal surgery. During the interval between diagnosis and surgery, a multimodal approach consisting of physical exercise and nutritional and psychological support could be employed to enhance physiologic reserve. Physical activity interventions aim to improve aerobic capacity, muscle strength and endurance. Nutritional support addressing malnutrition and sarcopenia also contributes to the achievement of the above-mentioned goals, particularly in patients undergoing cancer-related procedures. Psychological interventions targeting anxiety, depression and self-efficacy, as well as risk behavior modification (e.g., smoking cessation) seem to enhance recovery. However, there is a lack of standardization regarding these interventions, and the evidence about the impact of this multidisciplinary approach on the postoperative outcomes is still contradictory. This narrative review focuses on the physiological basis of surgical stress response and on the efficacy of prehabilitation, reflected mainly in the length of hospitalization and rates of postoperative complications. Multidisciplinary collaboration between surgeons, nutritionists, psychologists and physiotherapists was identified as the key to the success of prehabilitation programs. Synergizing prehabilitation and ERAS protocols significantly improves short-term surgical outcomes. Recent well-designed, randomized clinical trials revealed that this approach not only enhanced functional reserve, but also decreased the rates of postoperative complications and enhanced patient's overall quality of life, emphasizing the importance of its implementation in routine, elective, surgical care.

Enhanced Recovery After Surgery Protocol Decreases Hospital Length of Stay and Post-Operative Opioid Use for Thoracic Outlet Syndrome Surgical Decompression

OBJECTIVE

First rib resection for thoracic outlet syndrome (TOS) requires inpatient hospital stay and causes post-operative pain. We hypothesized that an enhanced recovery after surgery (ERAS) protocol, including multimodal pain management, would reduce post-operative narcotic use and length of stay (LOS).

METHODS

A retrospective single center case-control study (2016-2022) compared three protocols: 1) conventional peri-operative and pain management, 2) multimodal pain management with implantation of ropivacaine pump, and 3) ERAS peri-operative protocol including ropivacaine pump. Primary (inpatient opioid use and LOS) and secondary outcomes (complications and hospital cost) were assessed.

RESULTS

98 patients were evaluated (107 first rib resections). Compared to conventional pain management (median 33 mg/d), daily opioid use significantly decreased with both multimodal pain management alone (14 mg/d, P<0.0001) and full ERAS protocol (11 mg/d, P<0.0001). ERAS patients had shorter LOS than conventional management (1.44 d vs. 3.26 d, P<0.0001), but multimodal pain management alone did not. Complication rates were similar among the three groups, although ERAS patients had increased post-operative ED visits (n=4 (7.4%) vs. n=7 (27%), P=0.024) and readmissions (n=2 (3.7%) vs. n=5 (19%), P=0.034). Index hospital admission cost decreased between the ERAS and conventional groups (mean: $9,327 vs. $13,053, P=0.012). Total hospital cost including ED visits and readmissions, however, was similar between the three protocols.

CONCLUSIONS

Consistent with other areas of surgery, ERAS yielded a >2-fold decrease in LOS, multimodal pain management alone decreased opioid use, but did not reduce LOS. ERAS protocol increased ED visits and readmissions, suggesting that optimization to decrease readmissions will improve care and lower costs.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Enhanced Recovery Independently Lowers Failure to Rescue After Colorectal Surgery

BACKGROUND

High adherence to the enhanced recovery after surgery pathway reduces morbidity and mortality rates after elective colorectal surgery.

OBJECTIVE

To evaluate the effect of adherence to the enhanced recovery after surgery pathway on the failure to rescue rates after elective colorectal surgery.

DESIGN

Retrospective analysis of a prospective database.

PATIENTS

Adults (18 years or older) who underwent elective colorectal resection with anastomosis for benign and malignant disease.

SETTINGS

Prospective enrollment in 78 centers in Italy from 2019 to 2021.

INTERVENTIONS

All outcomes were measured 60 days after surgery. Several patient-, disease-, treatment-, hospital-, and complication-related variables were analyzed. After univariate analyses, independent predictors of the end points were identified through logistic regression analyses, presenting ORs and 95% CIs.

MAIN OUTCOME MEASURES

Failure to rescue after any adverse event, defined as the ratio between the number of deaths and the number of patients showing any adverse event; failure to rescue after any major adverse event, with the denominator represented by the number of patients showing any major adverse event.

RESULTS

An adverse event was recorded in 2321 of 8359 patients (27.8%), a major adverse event in 523 patients (6.3%), and death in 88 patients (1.0%). The failure to rescue rates were 3.8% after any adverse event and 16.8% after any major adverse event. Independent predictors of primary end points were identified among patient- (age, ASA class, and nutritional status), treatment- (type of resection), and complication-related (anastomotic leakage and reoperation) variables. Enhanced recovery pathway adherence of more than 70% independently reduced failure to rescue rates.

LIMITATIONS

Clustering from multicenter data and unmeasured confounding from observational data.

CONCLUSIONS

After elective colorectal resection, adherence of more than 70% to the enhanced recovery pathway independently decreased failure to rescue rates, along with other patient- or treatment-related factors. See Video Abstract .

LA RECUPERACIN MEJORADA REDUCE DE FORMA INDEPENDIENTE LA POSIBILIDAD DE FRACASO EN EL RESCATE DESPUS DE UNA CIRUGA COLORRECTAL

ANTECEDENTES:La alta adherencia a la vía de recuperación mejorada después de la cirugía reduce las tasas de morbilidad y mortalidad después de la cirugía colorrectal electiva.OBJETIVO:Evaluar el efecto de la adherencia a la vía ERAS en las tasas de fracaso en el rescate después de la cirugía colorrectal electiva.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.PACIENTES:Adultos (≥ 18 años) que se sometieron a una resección colorrectal electiva con anastomosis por enfermedad benigna y maligna.ESCENARIO:Inscripción prospectiva en 78 centros en Italia de 2019 a 2021.INTERVENCIONES:Todos los resultados se midieron a los 60 días después de la cirugía. Se analizaron varias variables relacionadas con el paciente, la enfermedad, el tratamiento, el hospital y las complicaciones para los resultados. Después de los análisis univariados, se identificaron los predictores independientes de los puntos finales a través de análisis de regresión logística, presentando razones de probabilidades e intervalos de confianza del 95%.PRINCIPALES MEDIDAS DE RESULTADOS:Fallo en el rescate después de cualquier evento adverso, definido como la relación entre el número de muertes y el número de pacientes que presentaron cualquier evento adverso; fallo en el rescate después de cualquier evento adverso mayor, con el denominador representado por el número de pacientes que presentaron cualquier evento adverso mayor.RESULTADOS:Se registró un evento adverso en 2321 de 8359 pacientes (27,8%), un evento adverso mayor en 523 pacientes (6,3%) y muerte en 88 pacientes (1,0%). Las tasas de fallo en el rescate fueron del 3,8% después de cualquier evento adverso y del 16,8% después de cualquier evento adverso mayor. Se identificaron predictores independientes de los criterios de valoración primarios entre las variables relacionadas con el paciente (edad, clase de la Sociedad Americana de Anestesiólogos, estado nutricional), el tratamiento (tipo de resección) y las complicaciones (fuga anastomótica, reoperación). La adherencia a la vía de recuperación mejorada > 70% redujo de forma independiente las tasas de fallo en el rescate.LIMITACIONES:Agrupamiento de datos multicéntricos y factores de confusión no medidos a partir de datos observacionales.CONCLUSIONES:Después de una resección colorrectal electiva, la adherencia > 70 % a la vía de recuperación mejorada disminuyó de manera independiente las tasas de fracaso en el rescate, junto con otros factores relacionados con el paciente o el tratamiento. (Traducción-Dr Osvaldo Gauto).

Role of transumbilical laparoendoscopic single-site surgery in the implementation ERAS in gynecology oncology: a retrospective study

Objective

The aim of the study was to verify the fast recovery effect of transumbilical laparoendoscopic single-site surgery by analyzing the operative and postoperative outcomes of patients with various gynecological malignancies in implementing The Enhanced Recovery After Surgery (ERAS) protocols.

Design

A retrospective study.

Setting

A university academic hospital.

Population or sample

Patients with cervical, endometrial or ovarian cancer undergoing transumbilical laparoendoscopic single-site surgery by a single experienced surgeon.

Methods

This was a retrospective consecutive single-center study of patients with cervical, endometrial, or ovarian cancer undergoing transumbilical laparoendoscopic single-site surgery for full surgical staging from November 2017 to January 2022.

Main outcome measures

The main outcomes were the perioperative outcomes in various surgeries, including surgery time, estimated blood loss, length of hospital stay, and complications.

Results

315 gynecologic malignant cases successfully experienced transumbilical laparoendoscopic single-site surgery (TU-LESS) between November 2017 and January 2022 in West China Second Hospital were incorporated, including 195 cervical cancers, 85 endometrial cancers and 35 ovarian cancers. The average age for patients is 47.48 (SD = 8.77). 152 (48.25%) patients have a history of previous pelvic and abdominal surgery. The average operating time and blood loss are 273.71 (SD = 87.12) minutes and 166.87 (SD = 237.09) ml, respectively. The average time for the first passage of flatus is 43.68 (SD = 29.75) hours. The hospitalization is 5.30 (SD = 2.42) days on average.

Conclusions

TU-LESS can enhance the recovery of patients who suffer from gynecological malignancies by implementing ERAS with fast flatus, less pain, shorter hospitalization and better rehabilitation.

Ending PJ paralysis for hospitalised patients: a quality improvement initiative

INTRODUCTION

PJ paralysis refers to the negative effects experienced by hospitalised patients who remain inactive and dressed in hospital clothing, and is a serious problem, affecting one-third of hospitalised older adults. This study evaluated the impact of a multicomponent hospital-based intervention to get patients out of bed, dressed in non-hospital attire, and moving around/mobilised.

METHODS

A 3-month quality improvement initiative was conducted at one hospital unit in Western Canada, which aimed for 50% of all patients to be dressed in their own clothing by midday, sitting up in a chair for all meals and mobilising to activities. Healthcare providers, patients and family members received PJ paralysis education, and a new patient dress code care standard and physician patient care order were implemented. Measures included: daily percentage of patients dressed and up for meals, weekly mobilisation rates, patient and provider satisfaction, and complication rates. Descriptive statistics were completed.

RESULTS

From July to October 2019, 70 patients participated. Approximately 14.3% of patients were dressed in their own clothing daily, 6.4% were sitting for all three meals, and the weekly mean number of patients mobilising to activities was 0.9 (SD 0.7) and mobilising for other reasons was 4.5 (SD 1.3). Five physician care orders were written. A trend was observed towards decreased falls, with minimal change in the number of staff, nursing assessment time and complication rates. Patient feedback revealed improvement in their self-identity.

CONCLUSION

Alleviating PJ paralysis in hospitalised older patients requires a complex multifactorial approach. Despite not achieving the project aim, the intervention demonstrated positive impacts without complications or additional workload, and ease of implementation suggests feasibility and (potential) long-term sustainability. Further research is needed to explore the experiences and perceptions of patients and healthcare providers to identify facilitators and barriers, which may aid in enhancing and implementing future interventions.

Perianastomotic pH Monitoring for Early Detection of Anastomotic Leaks in Gastrointestinal Surgery: A Systematic Review of the Literature

IntroductionAnastomotic leak (AL) represents a significant complication following gastrointestinal (GI) surgery, contributing to increased morbidity and mortality. pH monitoring has emerged as a potential diagnostic tool for the early detection of AL, but its effectiveness and clinical utility remain to be fully elucidated. This review aims to summarise the evidence regarding perianastomotic pH monitoring for AL detection.MethodsA systematic search of relevant databases was conducted to identify pre-clinical and clinical studies investigating pH monitoring for AL detection following GI surgery. Studies were screened by two independent reviewers based on predefined inclusion and exclusion criteria. Data were extracted and presented as a narrative synthesis.ResultsA total of 10 studies were included in the review, comprising animal studies (n = 2), and human studies in upper GI (n = 3) and colorectal (n = 5) patients. Consistent findings of lower pH values in patients with AL across various postoperative time points were demonstrated. There was diversity in the pH detection method, in addition to variable frequency and timing of pH monitoring. Four studies reported a shorter time for AL detection with pH monitoring vs conventional methods, although no statistical comparisons were used. No standard pH cut-off value for AL detection was identified.ConclusionpH monitoring shows potential as a diagnostic tool for the early detection of AL following GI surgery. While the existing evidence supports its potential utility, further research is required to establish standardised protocols and assess its clinical impact.

Enhanced recovery after surgery (ERAS) in stoma reversal surgery: a systematic review and meta-analysis

Stoma reversal surgery is known for relatively high complication rates. While Enhanced Recovery After Surgery (ERAS) protocols are extensively validated for colorectal surgery, their use in stoma reversal remains underexplored. This systematic review and meta-analysis evaluates clinical outcomes of stoma reversal surgery under ERAS protocols compared to standard care (SC) practices. Medline, EMBASE, and Cochrane Central databases were searched for studies that compared clinical outcomes of stoma reversal surgery under ERAS protocols versus SC practices. The endpoints of interest were length of stay (LOS), ileus, wound infection, anastomotic leak, time to first stool, overall, minor, and major postoperative complications, readmission rates, and reoperation rates. Mean difference (MD) was calculated for continuous variables and Odds Ratio (OR) for dichotomous variables. Statistical analysis was performed with R version 4.4.0. We included eight studies comprising 1322 patients. Among these, 603 (45.6%) followed an ERAS protocol, while 719 (54.4%) received SC practices. ERAS was associated with a significant decrease in LOS (MD -1.83; 95% CI -2.55 to -1.12; p < 0.01), wound infection (OR 0.47; 95% CI 0.23 to 0.97; p = 0.041), and time to first stool (MD -1.02; 95% CI -1.22 to -0.81; p < 0.01). No statistically significant difference was observed regarding ileus, anastomotic leak, overall, minor, and major postoperative complications, readmission rates, or reoperation rates. The implementation of ERAS protocols in stoma reversal procedures should be considered, as it was associated with a shorter length of hospital stay without increasing morbidity, and may even reduce complications such as wound infections.

Intraoperative Methadone: A New Enhanced Recovery After Surgery Pathway for Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. Previous studies have shown that just one dose of methadone can achieve better analgesia than multiple doses of short-acting opioids. This study aims to evaluate the effectiveness of our Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator flap breast reconstruction centered around a single weight-based intraoperative dose of methadone.

METHODS

The authors retrospectively reviewed patients from October 2020 to March 2021 to establish a historical control cohort (n = 29). The ERAS protocol was implemented in April 2021, and patients were prospectively enrolled in the ERAS cohort from April 2021 to January 2022 (n = 54). Primary outcomes compared between the ERAS and historical cohorts using univariate analysis were length of stay, postoperative opioid consumption, pain scores, heart rates, and incidence of tachycardia.

RESULTS

There was no difference in the length of stay between our ERAS and non-ERAS cohorts (P = 0.68). Patients in the ERAS pathway had significantly less opioid consumption at 12 hours postoperatively (P < 0.001), 24 hours postoperatively (P < 0.001), and throughout the entire admission (P = 0.002). Pain scores were significantly lower in the ERAS cohort at 24 hours postoperatively (P = 0.021) and throughout admission (P = 0.0051). The ERAS cohort had significantly lower heart rates at 12 hours postoperatively (P = 0.0014), 24 hours postoperatively (P < 0.001), and throughout admission (P < 0.001). The incidence of tachycardia was also significantly lower in the ERAS cohort (P = 0.029).

CONCLUSIONS

This preliminary data after newly instituting our ERAS protocol with a single dose of intraoperative methadone significantly reduced postoperative opioid analgesic usage, pain scores, heart rates, and incidence of tachycardia. This pilot study demonstrates that methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease postoperative pain, opioid use, and increase overall patient comfort and satisfaction.

The Enhanced Recovery After Surgery Pathway Is Safe, Feasible and Cost-Effective in Delayed Graft Function After Kidney Transplant

Background/Objectives: Enhanced recovery after surgery (ERAS) pathways are still underutilized in kidney transplantation (KT), and their feasibility after delayed graft function (DGF) is unknown. We aimed to evaluate safety and cost savings after ERAS implementation in KT recipients with DGF. Methods: A retrospective analysis of KT recipients enrolled in the ERAS program with DGF (≥1 dialytic treatment during the first postoperative week or creatinine≥ 2.5 mg/dL on postoperative day 10) between 2010 and 2019 was performed. Recipient, donor, and transplant data, outcomes, and 1-year post-KT costs were collected, comparing recipients within the ERAS target (≤5 days, "early discharge group") to those discharged later (>5 days, "late discharge group"). Results: Out of 170 KT recipients with DGF, 33 (19.4%) were in the "early discharge group" and 137 (80.5%) in the "late discharge group". Recipient, donor, and transplant characteristics were similar in the two groups. The length of hospital stay (LOS) of the "early discharge group" was significantly shorter, with fewer in-hospital dialysis sessions (p < 0.001) compared to the "late discharge group". One year post-KT, no significant differences were observed in postoperative complications, readmissions, or number of outpatient visits. Five-year graft and patient survival along with five-year graft function were similar between the two cohorts. First-year costs were significantly higher in the "late discharge group" (p < 0.001), with a median excess cost (Δ) of EUR 4515.76/patient. Factors influencing first-year costs post-KT were LOS for KT, recipient age, and use of expanded-criteria grafts. Conclusions: The ERAS approach is safe in KT recipients with DGF and allows for economic savings, while its implementation does not cause worse clinical outcomes in recipients.

Malnutrition and perioperative nutritional rehabilitation in major operations

Background

Malnutrition is a potentially preventable risk factor for surgery. This systematic review examines nutritional management strategies aiming to enhance surgical outcomes.

Methods

A systematic search was conducted in PubMed for English-language studies published between July 1, 2004, and July 1, 2024, involving adult surgical patients. Study selection focused on four key themes: (1) nutritional screening and assessment, (2) preoperative nutritional therapy, (3) nutritional support in critically ill surgical patients, and (4) postoperative nutritional rehabilitation. Studies in non-surgical cohorts, letters, and case reports were excluded. Reference lists of relevant studies were manually screened for additional sources.

Results

Of 2763 studies identified, 251 met the inclusion criteria and 85 were added after manual screening, contributing to a total of 341 papers for the review. The prevalence of malnutrition varied widely by procedure, with the highest rates observed in pancreatic and esophagogastric operations. Preoperative malnutrition was strongly associated with increased postoperative complications, infections, prolonged hospital stay, and higher mortality. The Malnutrition Universal Screening Tool (MUST) was effective in identifying at-risk patients. Preoperative nutritional interventions, including dietitian-led counseling, oral supplementation, and enteral or parenteral nutrition, may reduce complications and improve outcomes. Critically ill patients benefited from structured enteral and parenteral strategies. Early postoperative nutrition within enhanced recovery after surgery (ERAS) protocols are linked to less complications and shorter hospital stay.

Conclusion

Malnutrition significantly impacts surgical outcomes, necessitating early identification and intervention. Standardized management is key to improving recovery and reducing complications. Future research should focus on refining diagnostic tools, assessing nutritional requirements, optimizing perioperative nutritional strategies, and establishing long-term nutritional follow-up guidelines for surgical patients.

Low rate of rescue epidural analgesia after open colorectal surgery with intrathecal morphine: a retrospective cohort study

PURPOSE

The use of intrathecal morphine in open colorectal surgery has been limited despite being a promising analgesic alternative used in other types of open abdominal surgery. Intrathecal morphine has a higher success rate than thoracic epidural analgesia, the current standard method of analgesia in open colorectal surgery. Intrathecal morphine is occasionally used in open colorectal surgery when thoracic epidural analgesia placement fails and in instances when patients receive intrathecal morphine for a planned laparoscopic surgical procedure which is converted to laparotomy intraoperatively. This retrospective single-centre cohort study aimed to evaluate outcomes after intrathecal morphine in patients undergoing open colorectal surgery.

METHODS

All patients who received intrathecal morphine before open colorectal surgery at a secondary hospital in Sweden between 2016 and 2020 were included. Routinely collected data from the Swedish PeriOperative Registry and patients' medical records were reviewed, and data regarding postoperative outcomes including the incidence of postoperative rescue thoracic epidural analgesia and adverse events were extracted.

RESULTS

In total, 108 patients were included with a median age of 74 years. Four patients (4%) received rescue thoracic epidural analgesia postoperatively, and the median hospital length of stay was 8 days. The median intrathecal morphine dose was 200 µg. Respiratory complications occurred in two patients (2%).

CONCLUSION

The incidence of rescue thoracic epidural analgesia after intrathecal morphine in open colorectal surgery was low, and there were few adverse events. The results suggest that intrathecal morphine could be a viable alternative for postoperative pain management in open colorectal surgery.

Length of stay after colorectal surgery in Italy: the gap between "fit for" and "actual" discharge in a prospective cohort of 4529 cases

BACKGROUND

It is common to observe a gap between the day on which the discharge criteria are reached and the actual day of discharge after colorectal surgery. The aim of this study is to understand the reasons for this difference and its clinical impact on the overall length of stay (LOS).

METHODS

All patients enrolled in the prospective iCral3 study were analyzed regarding any difference and reason between the "fit for discharge" (FFD) and "actual discharge" (AD) dates. The association between the gap and the LOS in the whole population was then assessed through a multivariate regression model including other confounding variables.

RESULTS

The analysis included 4529 patients, with a median [IQR] LOS of 6 [4-8] days. The median [IQR] LOS was 6 [4-8] days in the no-gap group (3,910 patients, 86.3%), significantly lower (p < .001) than 7 [6-10] days in the gap group (619 patients, 13.7%). Among the gap reasons, the "need for postoperative rehabilitation" compared to "not willing to return home" and "social constraints" was associated with the longest LOS (9 [6.0-12.5] days, p < 0.001 vs other reasons). The existence of the gap independently determined a 2.3-day lengthening of LOS.

CONCLUSIONS

Among other factors, the gap between FFD and AD had an independent impact on LOS. The most frequent reasons for this gap were "not willing to return home" and "social constraint", while the "need for postoperative rehabilitation" had the greater clinical impact.

Impact of Multi-Institutional Enhanced Recovery after Surgery Protocol Implementation on Elective Colorectal Surgery Outcomes

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols aim to improve surgical patient outcomes, although their effectiveness may vary. This study assessed the impact of multi-institutional ERAS implementation on postoperative morbidity in patients undergoing elective colorectal surgery.

STUDY DESIGN

We conducted a multicenter retrospective cohort study using the American College of Surgeons NSQIP database from 2012 to 2020. We analyzed patient outcomes before (2012 to 2014) and after (2015 to 2020) ERAS implementation across 4 hospitals. Multivariable logistic regression was used to determine the impact of ERAS program on certain outcomes.

RESULTS

A total of 8,930 cases were analyzed: 3,573 in the pre-ERAS and 5,357 in the ERAS cohort. The ERAS cohort demonstrated significant reductions in superficial surgical site infection (SSI; 7.5% vs 2.5%, p < 0.001), deep SSI (0.6% vs 0.2%, p = 0.016), urinary tract infection (3.3% vs 1.5%, p < 0.001), pulmonary embolism (0.7% vs 0.4%, p = 0.022), deep vein thrombosis (1.4% vs 0.9%, p = 0.020), sepsis (3.0% vs 2.1%, p = 0.006), and other complications. Median length of stay decreased from 5 to 4 days (p < 0.001), and 30-day readmission rate dropped from 11.3% to 9.8% (p = 0.022). Overall, ERAS implementation was associated with a 35% decrease in the odds of all 30-day complications (odds ratio 0.65, 95% CI 0.59 to 0.73). There was no effect on 30-day (p = 0.962) or overall mortality rates (p = 0.732).

CONCLUSIONS

A standardized ERAS protocol, used across multiple institutions, significantly improves elective colorectal surgery outcomes, reducing complications, length of hospital stay, and readmissions. These findings support the broader implementation of ERAS to enhance patient care and reduce healthcarecosts.

The challenges of evidence-based prehabilitation in a real-life context for patients preparing for colorectal surgery-a cohort study and multiple case analysis

BACKGROUND

Multimodal prehabilitation programs are effective at reducing complications after colorectal surgery in patients with a high risk of postoperative complications due to low aerobic capacity and/or malnutrition. However, high implementation fidelity is needed to achieve these effects in real-life practice. This study aimed to investigate the implementation fidelity of an evidence-based prehabilitation program in the real-life context of a Dutch regional hospital.

METHODS

In this observational cohort study with multiple case analyses, all patients who underwent colorectal surgery from January 2023 to June 2023 were enrolled. Patients meeting the criteria for low aerobic capacity or malnutrition were advised to participate in a prehabilitation program. According to recent scientific insights and the local care context, this program consisted of four exercise modalities and three nutrition modalities. Implementation fidelity was investigated by evaluating: (1) coverage (participation rate), (2) duration (number of days between the start of prehabilitation and surgery), (3) content (delivery of prescribed intervention modalities), and (4) frequency (attendance of sessions and compliance with prescribed parameters). An aggregated percentage of content and frequency was calculated to determine overall adherence.

RESULTS

Fifty-eight patients intended to follow the prehabilitation care pathway, of which 41 performed a preoperative risk assessment (coverage 80%). Ten patients (24%) were identified as high-risk and participated in the prehabilitation program (duration of 33-84 days). Adherence was high (84-100%) in five and moderate (72-73%) in two patients. Adherence was remarkably low (25%, 53%, 54%) in three patients who struggled to execute the prehabilitation program due to multiple physical and cognitive impairments.

CONCLUSION

Implementation fidelity of an evidence-based multimodal prehabilitation program for high-risk patients preparing for colorectal surgery in real-life practice was moderate because adherence was high for most patients, but low for some patients. Patients with low adherence had multiple impairments, with consequences for their preparation for surgery. For healthcare professionals, it is recommended to pay attention to high-risk patients with multiple impairments and further personalize the prehabilitation program. More knowledge about identifying and treating high-risk patients is needed to provide evidence-based recommendations and to obtain higher effectiveness.

TRIAL REGISTRATION

NCT06438484.

Management of Recurrent Anal Cancer

Locoregional failure or recurrence after completion of chemoradiation for anal squamous cell carcinoma occurs in up to 27% of patients. Complete restaging with multimodality imaging should be performed to evaluate the extent of local disease and distant metastases. Extensive discussion in multidisciplinary tumor board and with necessary specialties is vital to assess possibility of R0 resection. Salvage surgery with R0 resection through abdominoperineal resection and possible exenteration is recommended with pedicled flap for perineal reconstruction. Five year overall survival rates are ∼50%. Successful management of recurrent anal squamous cell carcinoma relies on careful patient selection, multidisciplinary collaboration, and R0 resection.

Effectiveness of Implementation of an Enhanced Recovery Program in Bariatric Surgery

INTRODUCTION

While the adoption of ERAS protocols in bariatric surgery has increased, variability exists across centers, reflecting a spectrum of implementation stages. The objective of this study is to understand and increase awareness of the effectiveness of enhanced recovery after surgery (ERAS) protocols in bariatric surgery, given the specific perioperative difficulties and risks for this population. We aimed to study the association between implementation of the ERAS program in bariatric surgery and specific outcomes.

METHODS

Primary bariatric patients (≥18 y old) at a single academic institution were divided into pre-ERAS and post-ERAS groups. Poisson and quantile regressions were used to examine the association between the ERAS protocol and length of stay and cost, respectively. Logistic regression was used to assess the impact of ERAS on 30-d readmissions.

RESULTS

A total of 680 procedures were performed in the pre-ERAS cohort, compared to 1124 procedures post-ERAS. The median length of hospital stay was shorter, and median cost of surgery was lower for post-ERAS patients compared to pre-ERAS patients by 1 d (P = 0.001) and $2000, respectively. A higher proportion of patients in the pre-ERAS period had one or more unplanned readmissions compared to the post-ERAS period (P < 0.001). The ERAS protocol was associated with decreased length of stay (incidence rate ratio = 0.72, P < 0.001), decreased median cost (-$2230, P < 0.001), and lower risk of 30-d unplanned readmissions (odds ratio = 0.48, P < 0.001).

CONCLUSIONS

This study highlights the value of an enhanced recovery program in bariatric surgery, benefiting both patients and health systems.

Improving sustainability and mitigating the environmental impact of anaesthesia and surgery along the perioperative journey: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Correlation between inflammatory markers and enhanced recovery after surgery (ERAS) failure in laparoscopic colectomy

PURPOSE

To evaluate inflammatory markers to identify patients at risk of enhanced recovery after surgery (ERAS) failure following laparoscopic colectomy.

METHODS

We included patients who underwent laparoscopic colectomy between September 2020 and February 2023. ERAS failure was defined as intolerance of a soft diet on postoperative day (POD) 2, postoperative stay > 7 days, or readmission within 30 days postoperatively. Inflammatory markers were analyzed immediately postoperatively and on POD 1 and 3. All patients were subjected to the ERAS protocol and divided into success and failure groups.

RESULTS

Data from 402 patients (success, 330; failure, 72) were analyzed. The neutrophil-to-lymphocyte ratio (p < 0.001), platelet-to-lymphocyte ratio (p = 0.004), monocyte-to-lymphocyte ratio (p = 0.041), and C-reactive protein-to-albumin ratio (CAR; p < 0.001) were elevated in the failure group on POD 3. The immediate postoperative CAR was higher in the failure group (p = 0.045). ERAS failure occurred more frequently in patients with body mass index < 20 (p < 0.001), right colon tumors (p = 0.012), and longer operative time (p < 0.001).

CONCLUSIONS

This study demonstrated that inflammatory markers are associated with ERAS failure. Among the inflammatory markers, CAR might be the most potent indicator of ERAS failure following laparoscopic colectomy.

Review of frailty in geriatric surgical oncology

Frailty is a common phenomenon in older adult population and associated with an elevated risk of adverse health outcomes. Recent studies have demonstrated that patients with frailty undergoing surgery had a significantly higher morbidity and mortality compared to those without frailty. This is particularly important in patients with cancer because the prevalence of frailty is persistently high across a spectrum of primary cancers. Identifying frailty in oncological patients undergoing surgery may provide an important preoperative intervention opportunity to mitigate operative risks. In this review, we provide an overview of frailty and its association with other geriatric syndromes. We will also review the impact of frailty on postoperative outcomes focusing on the field of surgical oncology. We then describe currently available tools to objectively measure frailty to provide clinicians with various practical tools that may be adopted in their clinical practice. Finally, we will describe potential interventional programs, including the recently introduced Geriatric Surgery Verification program by the American College of Surgeons, that may be institutionally adopted to mitigate postoperative complications and improve meeting patient-centered goals in the frail patient population.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery

The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.

Psychiatric Diagnoses Are Associated With Postoperative Disparities in Patients Undergoing Major Colorectal Operations

BACKGROUND

Over 50% of hospitalized patients have comorbid psychiatric diagnoses, resulting in increased risk of morbidity such as longer lengths of stay, worse health-related quality of life, and increased mortality. However, data regarding colorectal surgery postoperative outcomes in patients with psychiatric diagnoses (PD) are limited.

METHODS

We queried a single institution's National Surgical Quality Improvement Program from 2013-2019 for major colorectal procedures. Postsurgical outcomes for patients with and without PD were compared. Primary outcomes were prolonged length of stay (pLOS) and 30-day readmission.

RESULTS

From a total of 1447 patients, 402 (27.8%) had PD. PD had more smokers (20.9% vs 15%) and higher mean body mass index (29.1 kg/m2 vs 28.2 kg/m2). Bivariate outcomes showed more surgical site infections (SSI) (10.2% vs 6.12%), reoperation (9.45% vs 6.35%), and pLOS (34.8% vs 29.0%) (all P values <.05) in the PD group. On multivariate analysis, PD had higher likelihood of reoperation (OR 1.53, 95% CI: [1.02-2.80]) and SSI (OR 1.82, 95% CI: [1.25-2.66]).

DISCUSSION

Psychiatric diagnoses are a risk factor for adverse outcomes after colorectal procedures. Further studies are needed to evaluate the benefit of perioperative mental health support services for these patients.

Early Postoperative Prediction of Complications and Readmission After Colorectal Cancer Surgery Using an Artificial Neural Network

BACKGROUND

Early predictors of postoperative complications can risk-stratify patients undergoing colorectal cancer surgery. However, conventional regression models have limited power to identify complex nonlinear relationships among a large set of variables. We developed artificial neural network models to optimize the prediction of major postoperative complications and risk of readmission in patients undergoing colorectal cancer surgery.

OBJECTIVE

This study aimed to develop an artificial neural network model to predict postoperative complications using postoperative laboratory values and compare the accuracy of models to standard regression methods.

DESIGN

This retrospective study included patients who underwent elective colorectal cancer resection between January 1, 2016, and July 31, 2021. Clinical data, cancer stage, and laboratory data from postoperative days 1 to 3 were collected. Complications and readmission risk models were created using multivariable logistic regression and single-layer neural networks.

SETTING

National Cancer Institute-Designated Comprehensive Cancer Center.

PATIENTS

Adult patients with colorectal cancer.

MAIN OUTCOME MEASURES

The accuracy of predicting postoperative major complications, readmissions, and anastomotic leaks using the area under the receiver operating characteristic curve.

RESULTS

Neural networks had larger areas under the curve for predicting major complications compared to regression models (neural network 0.811; regression model 0.724, p < 0.001). Neural networks also showed an advantage in predicting anastomotic leak ( p = 0.036) and readmission using postoperative day 1 to 2 values ( p = 0.014).

LIMITATIONS

Single-center, retrospective design limited to cancer operations.

CONCLUSIONS

In this study, we generated a set of models for the early prediction of complications after colorectal surgery. The neural network models provided greater discrimination than the models based on traditional logistic regression. These models may allow for early detection of postoperative complications as early as postoperative day 2. See the Video Abstract .

PREDICCIN POST OPERATORIA TEMPRANA DE COMPLICACIONES Y REINGRESO DESPUS DE LA CIRUGA DE CNCER COLORRECTAL MEDIANTE UNA RED NEURONAL ARTIFICIAL

ANTECEDENTES:Los predictores tempranos de complicaciones postoperatorias pueden estratificar el riesgo de los pacientes sometidos a cirugía de cáncer colorrectal. Sin embargo, los modelos de regresión convencionales tienen un poder limitado para identificar relaciones no lineales complejas entre un gran conjunto de variables. Desarrollamos modelos de redes neuronales artificiales para optimizar la predicción de complicaciones postoperatorias importantes y riesgo de reingreso en pacientes sometidos a cirugía de cáncer colorrectal.OBJETIVO:El objetivo de este estudio fue desarrollar un modelo de red neuronal artificial para predecir complicaciones postoperatorias utilizando valores de laboratorio postoperatorios y comparar la precisión de estos modelos con los métodos de regresión estándar.DISEÑO:Este estudio retrospectivo incluyó a pacientes que se sometieron a resección electiva de cáncer colorrectal entre el 1 de enero de 2016 y el 31 de julio de 2021. Se recopilaron datos clínicos, estadio del cáncer y datos de laboratorio del día 1 al 3 posoperatorio. Se crearon modelos de complicaciones y riesgo de reingreso mediante regresión logística multivariable y redes neuronales de una sola capa.AJUSTE:Instituto Nacional del Cáncer designado Centro Oncológico Integral.PACIENTES:Pacientes adultos con cáncer colorrectal.PRINCIPALES MEDIDAS DE RESULTADO:Precisión de la predicción de complicaciones mayores postoperatorias, reingreso y fuga anastomótica utilizando el área bajo la curva característica operativa del receptor.RESULTADOS:Las redes neuronales tuvieron áreas bajo la curva más grandes para predecir complicaciones importantes en comparación con los modelos de regresión (red neuronal 0,811; modelo de regresión 0,724, p < 0,001). Las redes neuronales también mostraron una ventaja en la predicción de la fuga anastomótica ( p = 0,036) y el reingreso utilizando los valores del día 1-2 postoperatorio ( p = 0,014).LIMITACIONES:Diseño retrospectivo de un solo centro limitado a operaciones de cáncer.CONCLUSIONES:En este estudio, generamos un conjunto de modelos para la predicción temprana de complicaciones después de la cirugía colorrectal. Los modelos de redes neuronales proporcionaron una mayor discriminación que los modelos basados en regresión logística tradicional. Estos modelos pueden permitir la detección temprana de complicaciones posoperatorias tan pronto como el segundo día posoperatorio. (Traducción-Dr. Mauricio Santamaria ).

An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery

BACKGROUND

Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery.

METHODS

This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery.

RESULTS

The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created.

CONCLUSION

Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.

A Retrospective Comparison Trial Investigating Aggregate Length of Stay Post Implementation of Seven Enhanced Recovery After Surgery (ERAS) Protocols between 2015 and 2022

(1) Introduction: Enhanced Recovery After Surgery (ERAS) protocols can create a cultural shift that will benefit patients by significantly reducing patient length of stay when compared to an equivalent group of surgical patients not following an ERAS protocol. (2) Methods: In this retrospective study of 2236 patients in a multi-center, community-based healthcare system, matching was performed based on a multitude of variables related to demographics, comorbidities, and surgical outcomes across seven ERAS protocols. These cohorts were then compared pre and post ERAS protocol implementation. (3) Results: ERAS protocols significantly reduced hospital length of stay from 3.0 days to 2.1 days (p <0.0001). Additional significant outcomes included reductions in opioid consumption from 40 morphine milligram equivalents (MMEs) to 20 MMEs (p <0.001) and decreased pain scores on postoperative day zero (POD 0), postoperative day one (POD 1), and postoperative day two (POD 2) when stratified into mild, moderate, and severe pain (p <0.001 on all three days). (4) Conclusions: ERAS protocols aggregately reduce hospital length of stay, pain scores, and opioid consumption.

Determinants of late recovery following elective colorectal surgery

BACKGROUND

Despite the implementation of enhanced recovery protocols, a significant proportion of patients experience delayed recovery. Identifying potential determinants of delayed recovery is crucial for optimizing perioperative protocols and tailoring patient pathways.

OBJECTIVE

This study aims to identify possible determinants of delayed recovery.

DESIGN

Retrospective observational study based on a prospectively collected dedicated register spanning from 2015 to 2022.

SETTING

Twenty-two Italian hospitals specializing in high-volume colorectal surgery and trained in enhanced recovery protocols.

PATIENTS

Patients undergoing elective colorectal resection for cancer or benign disease.

MAIN OUTCOME MEASURES

Recovery status on postoperative day 2. Late recovery was defined as the failure to meet at least two indicators of postoperative recovery (oral feeding, removal of the urinary catheter, cessation of intravenous fluids, and mobilization) on postoperative day 2.

RESULTS

A total of 1535 patients were analyzed. The median overall adherence to pre- and intraoperative enhanced recovery protocol items was 75.0% (range: 66.6%-83.3%). Delayed recovery was observed in 487 (31.7%) patients. Multiple regression analysis revealed six enhanced recovery protocol items that independently positively influenced postoperative recovery: pre-admission counseling (adjusted odds ratio [aOR] 2.596), a preoperative carbohydrate drink (aOR 1.948), intraoperative fluid infusions < 7 ml/kg/h (aOR 1.662), avoidance of thoracic epidural analgesia (aOR 2.137), removal of nasogastric tube at the end of surgery (aOR 4.939), and successful laparoscopy (aOR 2.341). The rate of delayed recovery progressively decreased with increasing adherence to these six positive items, reaching 13.0% when all items were applied (correlation coefficient [r] = - 0.99, p < 0.001).

LIMITATIONS

This study is limited by its retrospective analysis of a register containing data from multiple centers and a diverse patient population.

CONCLUSIONS

Adherence to specific pre- and intraoperative enhanced recovery protocol items, including counseling, preoperative carbohydrate intake, restrictive intraoperative fluid management, avoidance of thoracic epidural analgesia, early removal of nasogastric tube, and successful laparoscopy, appears crucial for promoting early recovery following elective colorectal resection.

Oncology Intensive Care Units: Distinguishing Features and Clinical Considerations

The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.

Enhanced recovery program in ambulatory pediatric urology: A quality improvement initiative

BACKGROUND

Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center.

METHODS

A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used.

RESULTS

The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged.

CONCLUSIONS

This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.

Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis

Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.

Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis

Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.

Contemporary Perioperative Nutritional Care

Over the last decades, surgical complication rates have fallen drastically. With the introduction of new surgical techniques coupled with specific evidence-based perioperative care protocols, patients today run half the risk of complications compared with traditional care. Many patients who in previous years needed weeks of hospital care now recover and can leave in days. These remarkable improvements are achieved by using nutritional stress-reducing care elements for the surgical patient that reduce metabolic stress and allow for the return of gut function. This new approach to nutritional care and how it is delivered as an integral part of enhancing recovery after surgery are outlined in this review. We also summarize the new and increased understanding of the effects of the routes of delivering nutrition and the role of the gut, as well as the current recommendations for artificial nutritional support.

Strict compliance to a thoracic enhanced recovery after surgery protocol is associated with improved outcomes compared with partial compliance: A prospective cohort study

BACKGROUND

Benefits of thoracic enhanced recovery after surgery programs have been described. However, there is ongoing discussion on the importance of full protocol compliance. The objective of this study was to determine whether strict adherence to an enhanced recovery after surgery protocol leads to further improvement in outcomes compared with less strict compliance.

METHODS

This was a multihospital prospective cohort study of all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023, with comparison with a historical control from January 2019 to April 2021. Compliance to 5 key protocol elements was tracked. Patients were grouped into high- and low-compliance cohorts, defined as adherence to 4-5/5 or 0-3/5 elements, respectively. The primary outcome was overall morbidity; secondary outcomes included cardiac, respiratory, and infectious morbidity and length of stay.

RESULTS

Of the 960 patients, 429 (44.7%) were enhanced recovery after surgery patients and 531 (55.3%) were in the historical control group. Across all patients, 250 (26.0%) were considered high compliance and 710 (74.0%) were considered low compliance. After adjustment for enhanced recovery after surgery status and confounders, the association between high compliance and improved outcomes persisted for all but infectious morbidity. Compared with low compliance, high compliance was associated with decreased odds of any morbidity (0.41 [95% CI, 0.22-0.77]), cardiac morbidity (0.31 [0.11-0.91]), respiratory morbidity (0.46 [0.23-0.90]) and decreased length of stay (0.38 [0.18-0.87]).

CONCLUSION

Enhanced recovery after surgery protocols improve outcomes after anatomic lung resection. Increasing compliance to individual elements (>80%) further improves patient outcomes. Continued efforts should be directed at increasing compliance to individual protocol elements.

Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience

BACKGROUND

The main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital.

METHODS

A prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018-2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013-2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS.

RESULTS

Baseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001).

CONCLUSIONS

Although limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcome and Measures

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

Results

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

Conclusions and Relevance

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

Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study

INTRODUCTION

It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP.

MATERIALS AND METHODS

Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined.

RESULTS

Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001).

CONCLUSIONS

The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

Clinical Impact of an Enhanced Recovery Program for Lower-extremity Bypass

OBJECTIVE

To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB).

BACKGROUND

ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown.

METHODS

Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed.

RESULTS

Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002).

CONCLUSIONS

This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery

BACKGROUND

Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models.

RESULTS

The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05).

CONCLUSION

There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Outcomes before and after Implementation of the ERAS (Enhanced Recovery after Surgery) Protocol in Open and Laparoscopic Colorectal Surgery: A Comparative Real-World Study from Northern Italy

Enhanced Recovery After Surgery (ERAS) protocols have changed perioperative care, aiming to optimize patient outcomes. This study assesses ERAS implementation effects on postoperative complications, length of hospital stay (LOS), and mortality in colorectal cancer (CRC) patients. A retrospective real-world analysis was conducted on CRC patients undergoing surgery within a Northern Italian Cancer Registry. Outcomes including complications, re-surgeries, 30-day readmission, mortality, and LOS were assessed in 2023, the year of ERAS protocol adoption, and compared with data from 2022. A total of 158 surgeries were performed, 77 cases in 2022 and 81 in 2023. In 2023, a lower incidence of postoperative complications was observed compared to that in 2022 (17.3% vs. 22.1%), despite treating a higher proportion of patients with unfavorable prognoses. However, rates of reoperations and readmissions within 30 days post-surgery increased in 2023. Mortality within 30 days remained consistent between the two groups. Patients diagnosed in 2023 experienced a statistically significant reduction in LOS compared to those in 2022 (mean: 5 vs. 8.1 days). ERAS protocols in CRC surgery yield reduced postoperative complications and shorter hospital stays, even in complex cases. Our study emphasizes ERAS' role in enhancing surgical outcomes and recovery.

Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention.

METHODS

A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items.

RESULTS

Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of -0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68).

CONCLUSION

Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. Trial registration number NCT04037787.

Enhanced Recovery after Surgery for Cesarean Delivery: A Quality Improvement Initiative

OBJECTIVE

Enhanced recovery after surgery (ERAS) was developed as a way to standardize clinical care pathways and communication across multidisciplinary teams to improve patient recovery and reduce hospital length of stay (LOS). Our objective was to implement an ERAS protocol for cesarean delivery (ERAS-CD) and evaluate its efficacy in reducing LOS.

STUDY DESIGN

An ERAS-CD program was implemented at our institution in October 2018. Patients undergoing scheduled and unscheduled CD were maintained on an ERAS pathway of care, which included preoperative hydration, standardized intraoperative protocols, and postoperative analgesic regimens as well as early feeding, urinary catheter removal, and ambulation. We compared LOS after delivery (calculated from time of delivery to discharge), readmission rates, health care disparities and postoperative opioid prescribing practices before (October 2017-September 2018) and after (November 2018-October 2019) ERAS implementation. We excluded any outliers, defined as a LOS >25 days. Continuous data are expressed as mean ± standard deviation. Student's t-test and Chi-square were used for statistical comparison with p <0.05 considered statistically significant.

RESULTS

There were 1,729 patients who had a CD in the pre-ERAS group with a mean LOS after delivery of 3.32 ± 6.19 days. In the post-ERAS group, 1,753 women underwent CD with a mean LOS after delivery of 2.85 ± 5.79 days, a statistically significant difference from the pre-ERAS group (p <0.001). There was no difference in readmission rates between pre- and post-ERAS implementation groups (1.9 vs. 2.2%, p = 0.53). There was a reduction in health care disparities in postoperative LOS, when stratifying by race-ethnicity, and a reduction in opioid prescribing practices after the implementation of the program.

CONCLUSION

With the implementation of an ERAS-CD program, we achieved a reduced LOS, without increasing readmission rates, and saw a reduction in health care disparities and opioid dispensing. A shorter LOS could offer an enhanced patient experience, as well as improved and equitable perioperative outcomes.

KEY POINTS

· ERAS-CD is associated with a reduction in postoperative hospital length of stay.. · A reduction in health care disparities by race-ethnicity was observed with the implementation of ERAS-CD.. · A reduction in opioid dispensing was observed with the implementation of ERAS-CD..

Retrospective Analysis of Postoperative Nonhepatic Outcomes Following Major Liver Resection

Background Liver surgery is a major and challenging procedure for the surgeon, the anesthetist, and the patient. The objective of this study was to evaluate the postoperative nonhepatic complications of patients undergoing liver resection surgery with perioperative factors. Methods We retrospectively analyzed 79 patients who underwent liver resection surgeries at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan, from July 2015 to December 2022. Results The mean age at the time of surgery was 53 years (range: 3-77 years), and the mean BMI was 26.43 (range: 15.72-38.0 kg/m2). Of the total patients, 44.3 % (n = 35) had no comorbidities, 26.6% (n=21) had one comorbidity, and 29.1% (n=23) had two or more comorbidities. Patients in whom the blood loss was more than 375 ml required postoperative oxygen inhalation with a significant relative risk of 2.6 (p=0.0392) and an odds ratio of 3.5 (p=0.0327). Similarly, patients who had a surgery time of more than five hours stayed in the hospital for more than seven days, with a statistically significant relative risk of 2.7 (p=0.0003) and odds ratio of 7.64 (p=0.0001). The duration of surgery was also linked with the possibility of requiring respiratory support, with a relative risk of 5.0 (p=0.0134) and odds ratio of 5.73 (p=0.1190). Conclusion Patients in our cohort who had a prolonged duration of surgery received an increased amount of fluids, and a large volume of blood loss was associated with prolonged stay in the ICU (>2 days), hospital admission (>7 days), ICU readmission, and increased incidence of cardiorespiratory, neurological, and renal disturbances postoperatively.