Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

Assessment of the adherence to perioperative nutritional care protocols in Brazilian hospitals: The PreopWeek study

OBJECTIVES

The study (PreopWeek) aimed to assess the perioperative nutritional care for major surgical patients in Brazilian hospitals, focusing on adherence to emerging multimodal protocols like Enhanced Recovery After Surgery and Acceleration of Total Postoperative Recovery.

METHODS

An observational cross-sectional study was conducted in Brazilian hospitals enrolled voluntarily from June 19 to June 23, 2023 (convenience sample). Data were collected through patient interviews and medical records review.

RESULTS

Data from 219 patients up to the fifth postoperative day or postoperative discharge across 24 hospitals were analyzed. Only three hospitals (12.5%) had established institutional perioperative protocols. Most of the patients were female (60.3%) and over 60 y old (81.7%) and underwent gastrointestinal (34.7%) or orthopedic (33.3%) surgeries. General and nutritional preoperative counseling was provided to a respective 82.2% and 62.6% of the patients. Only 25.7% of the patients had preoperative fasting for up to 3 h, and 28.8% received carbohydrate-rich supplements. Immunonutrition was not received by 43.8% at any point. Although most started postoperative refeeding within 24 h (81.7%), 39.4% started with a liquid diet and 70.6% reported postoperative immobilization in the first 24 h. Notable differences were observed between hospitals with and without protocols. Hospitals with institutional protocols reported significantly more preoperative exercises and nutritional counseling and higher adherence rates for all the perioperative protocols.

CONCLUSIONS

Our study demonstrates a lack of adherence to the multimodal protocols, even in hospitals with institutional protocols. Future educational programs are necessary to improve this result.

Impact of tranexamic acid use in total hip replacement patients: A systematic review and meta-analysis

Purpose

Tranexamic acid (TXA) dose in the context of primary complete hip replacements (THA) is still a hot debate about the best way to administer TXA. The need to select the most efficient and secure TXA dosing regimen, taking into account elements like perioperative bleeding, postoperative complications, and patient outcomes, has been emphasized by numerous studies. Improving clinical procedures and the general efficacy and safety of employing TXA in THA surgeries requires addressing this ongoing debate.

Methods

For this systematic review, We looked at the safety and efficacy of administering TXA intravenously (iTXA) and topically (tTXA) during THA. A thorough search turned up ten randomized controlled trials with 1295 individuals. Parameters evaluated included blood loss, Hb level on the day following surgery, transfusion rates, and drainage volume.

Results

Strategies had comparable impacts on deep vein thrombosis occurrences and wound complications. iTXA produced considerably less intraoperative blood loss (WMD = -12.687), concealed blood loss (WMD = 14.276), and the greatest hemoglobin drop (WMD = -0.400) when compared to tTXA.

Conclusion

Both administration techniques were secure and efficient in primary THA, although iTXA showed superior results in lowering blood loss and Hb decline.

Effectiveness of tramadol or topic lidocaine compared to epidural or opioid analgesia on postoperative analgesia in laparoscopic colorectal tumor resection

BACKGROUND

Chronic postoperative pain is the most common postoperative complication that impairs quality of life. Postoperative pain gradually develops into neuropathic pain. Multimodal analgesia targets multiple points in the pain pathway and influences the mechanisms of pain chronification.

PATIENTS AND METHODS

We investigated whether a lidocaine patch at the wound site or an infusion of metamizole and tramadol can reduce opioid consumption during laparoscopic colorectal surgery and whether the results are comparable to those of epidural analgesia. Patients were randomly divided into four groups according to the type of postoperative analgesia. Group 1 consisted of 20 patients who received an infusion of piritramide. Group 2 consisted of 21 patients who received an infusion of metamizole and tramadol. Group 3 consisted of 20 patients who received patient-controlled epidural analgesia. Group 4 consisted of 22 patients who received piritramide together with a 5% lidocaine patch on the wound site. The occurrence of neuropathic pain was also investigated.

RESULTS

Piritramide consumption was significantly lowest in group 3 on the day of surgery and on the first and second day after surgery. Group 4 required significantly less piritramide than group 1 on the day of surgery and on the first and second day after surgery. The group with metamizole and tramadol required significantly less piritramide than groups 1 and 4 on the first and second day after surgery. On the day of surgery, this group required the highest amount of piritramide.

CONCLUSIONS

Weak opioids such as tramadol in combination with non-opioids such as metamizole were as effective as epidural analgesia in terms of postoperative analgesia and opioid consumption. A lidocaine patch in combination with an infusion of piritramide have been able to reduce opioid consumption.

National trends and costs of same day discharge in patients undergoing elective minimally invasive colectomy

BACKGROUND

Enhanced Recovery Pathways (ERPs) have enabled safe same day discharge (SDD) of select patients after elective minimally invasive colectomy. We aimed to analyse the financial impact of SDD in these cases.

METHODS

We queried the Nationwide Readmission Database (2016-2019) and included patients with a hospital length of stay ≤2 days after minimally invasive elective colectomy. Propensity score matched pairs of patients discharged on the day of the operation and those discharged on post operative day 1 or 2 were compared. Our primary outcome was the combined cost of hospitalization and readmission.

RESULTS

SDD patients had lower comorbidity (33 ​% vs 21 ​%) and illness severity (79 ​% vs 63 ​%), more Medicare insurance (44 ​% vs 38 ​%), and more benign neoplasms (52 ​% vs 17 ​%). Most SDD patients underwent right colectomy (89 ​%). Across 647 matched pairs, total cost was significantly lower in SDD patients ($8000 vs. $12,900; p ​< ​0.001) due to cheaper index hospitalizations. No difference in readmission rates or costs emerged.

CONCLUSION

SDD reduced costs of index hospitalization and may be cost-effective in a select cohort of healthier patients.

Navigating the Surgical Pathway for Frail, Older Adults Undergoing Colorectal Surgery

Adults ≥ 65 years of age comprise nearly 20% of the U.S. population and over half of surgical patients. Older adults, particularly when frail, may require additional preoperative evaluation and counseling, specialized hospital care, and may experience more noticeable physical and cognitive changes than younger or healthier patients. Surgeons can assess frailty and risk using several frailty measures, as data exist demonstrating worse perioperative outcomes among patients undergoing colorectal surgery. Prehabilitation programs have not been shown to improve surgical outcomes for colorectal surgery patients but may help maintain physical function or hasten recovery to baseline around the time of surgery, particularly for frail patients. Functional decline and delirium are common postoperatively in older adult patients, particularly those who are frail at baseline, and should be discussed with at-risk older adults. Primary care physicians and geriatricians can help with in-depth evaluation of frailty and geriatric syndromes. Special attention to the risks, outcomes, and care of older adults considering or undergoing colorectal surgery can help inform decision-making, which may facilitate goal-concordant care.

Association between early enteral nutrition and length of stay in neonates with congenital bowel obstruction: A retrospective cohort study

BACKGROUND

The optimal feeding strategy for postoperative neonatal patients with congenital bowel obstruction is widely debated. This study aims to evaluate perioperative characteristics and postoperative nutrition practices for patients with congenital bowel obstruction. We hypothesized that earlier introduction of enteral nutrition (EN) is associated with shorter hospital stays and increased weight gain velocities.

METHODS

We performed a retrospective cohort study on neonatal patients (<30 days old) admitted to a pediatric referral hospital who underwent an operation for bowel obstruction between 2010 and 2020. Demographic information, clinical characteristics, and feeding characteristics were collected. Associations between early EN (EEN), defined as commencement of enteral feeding within 5 days of surgery, and perioperative characteristics were analyzed with SAS 9.4.

RESULTS

Of the 97 neonates with congenital bowel obstruction, 36 patients received EEN. Sex, gestational age, and ethnicity were similar between groups. Patients receiving EEN were more likely to have a diagnosis of malrotation, anorectal malformation, or annular pancreas (P = 0.04). Patients receiving EEN weaned from parenteral nutrition earlier (9 vs 17 days, P = 0.005). Receiving EEN was associated with shorter median hospital stay (16 vs 29 days, P < 0.0001). Weight gain velocities at the 2-month follow-up were greater for patients receiving EEN (8.02 vs 7.00 g/kg/day, P = 0.04) with the difference dissipating at 6 months.

CONCLUSION

EEN was more likely provided in patients with certain operative diagnoses and was associated with improved outcomes. Creating and implementing an EEN protocol in congenitally obstructed neonates may lead to shorter hospital stays and improved outcomes.

The Role of Diet in Inflammatory Bowel Disease Onset, Disease Management, and Surgical Optimization

The concept of using diet as therapy in inflammatory bowel disease is of interest to clinicians and patients. Once considered to play a minor role, diet is now known to not only affect disease onset but may also serve as a therapeutic tool for inducing and maintaining remission and improving surgical outcomes. Further research is needed to fully elucidate how, when, and in whom diet therapies may be best applied to improve clinical and disease outcomes. The aim of this review was to summarize current research findings and serve as a tool to help facilitate patient-clinician conversations.

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

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

"Opioid free colorectal surgery: Outcomes of successful non-opiate colorectal surgery in a rural community teaching hospital"

BACKGROUND

Opiates present challenges due to side effects, including prolonged hospitalization and delayed bowel function. Enhanced Recovery After Surgery (ERAS) protocols advocate for multimodal pain management, yet few studies explore entirely non-opiate approaches.

METHODS

134 elective ERAS colorectal surgery patients were reviewed from January 2019 to June 2020 ​at a single institution, with surgery performed by a single surgeon. Endpoints were pain scores, length of stay (LOS), and mortality.

RESULTS

Forty patients were included in the non-opiate cohort. Mann Whitney-U test found that postoperatively, non-opiate patients spent significantly less time in moderate or severe pain (p ​< ​.001). There was no significant difference between study groups (non-opiate and opiate) for the no or mild pain categories, LOS, or mortality. Risk factors for opiate use were younger age and prior opiate use. Gender, ASA class, stoma creation, malignancy, and surgical approach were not associated with increased opiates.

CONCLUSION

Non-opiate approaches in colorectal surgery are feasible and comparable to opiate regimens in our patient cohort.

Surgical Recovery Through the Lens of Patients with Colorectal Disease: A Qualitative Study in an Enhanced Recovery after Surgery Setting

BACKGROUND

As perioperative care shifts to a more patient-centered model, understanding needs and experiences of patients is vital. Gaining such insight can enhance the alignment of care with patient priorities, encouraging adherence to recovery-oriented interventions. We aimed to explore patient-defined recovery and the elements that modify the recovery process for patients with colorectal disease under enhanced recovery after surgery (ERAS) care.

STUDY DESIGN

A qualitative study was conducted at an ERAS-participating hospital in Alberta, Canada, between April 2018 and June 2019. A co-design focus group set the research direction, and semistructured interviews were conducted postoperatively in-hospital or within 3 months postdischarge. Diverse patient ages and colorectal conditions were targeted through purposive sampling. Interviews were transcribed verbatim and analyzed through manifest and latent content analysis.

RESULTS

Twenty patients with mean age 62 (SD 13) years and 45% with cancer (17 interview, 2 focus group + interview, and 1 focus group only) were enrolled. Recovery was defined by patients as the return to normal routines and four themes were identified. First, phases of recovery: recovery was described as multidimensional phases distinctively as early, late or long-term, and the endpoint. Second, recovery facilitators: recovery was supported through positive mindsets, conscious recovery, and taking an active role. Third, recovery barriers: recovery was hindered by negative mindsets and treatment side effects. Finally, recovery catalysts: communication, autonomy, and expectations facilitated active or passive recovery.

CONCLUSIONS

Our patient-oriented recovery model may contribute a new dimension to the ERAS framework by capturing patients' recovery experiences. Further research is encouraged to explore its value in enhancing patient-centered care within ERAS.

The effect of supplementary parenteral nutrition with different energy intakes on clinical outcomes of patients after gastric cancer surgery

BACKGROUND

To investigate the effect of postoperative supplementary parenteral nutrition (SPN) containing varying energy intake levels during the early postoperative period on the clinical outcomes of patients diagnosed with gastric cancer.

METHODS

Data from 237 patients, who were diagnosed with gastric cancer between January 2016 and June 2022, were retrospectively analyzed. Patients were divided into 2 groups based on mean daily SPN energy intake: low (L-SPN; < 20 kcal/kg/day); and high (H-SPN; ≥ 20 kcal/kg/day). Data regarding gender, age, body mass index, preoperative Nutrition Risk Screening 2002 (NRS 2002) score, American Society of Anesthesiologists Physical Status classification system, age-adjusted Charlson Comorbidity Index, diabetes, hypertension, chronic lung disease, and the Tumor-Node-Metastasis (TNM [Eighth edition]) classification were collected for propensity score matching (PSM). Postoperative indicators were monitored. A power analysis was performed during the design phase of this study to ensure that statistical power exceeded 80% to reliably detect differences between the 2 groups.

RESULTS

After PSM, data from 128 patients were analyzed (H-SPN, n = 64; L-SPN, n = 64). The H-SPN group experienced shorter postoperative hospital stay (8.11 ± 6.00 days vs. 10.38 ± 7.73 days; P = 0.045) and a lower number of infectious complications (36 [56.3%] vs. 60 [93.8%]; P < 0.001), particularly pulmonary infections, compared with the L-SPN group. Additionally, no increase in hospitalization costs or non-infectious complications occurred in the H-SPN group. Subgroup analysis revealed that H-SPN significantly reduced the incidence of infectious complications among those < 65 years of age (hazard ratio [HR] [95% confidence interval (CI) 0.240 0.069-0.829]; P = 0.024), NRS 2002 score ≥ 3 (HR 0.417 [95% CI 0.156-0.823]; P = 0.028), age-adjusted Charlson Complexity Index < 2 (HR 0.106 [95% CI 0.013-0.835]; P = 0.033), and TNM stage III (HR 0.504 [95% CI 0.224-0.921]; P = 0.046).

CONCLUSIONS

H-SPN effectively reduced postoperative infectious complications and the length of hospital stay, suggesting that early postoperative H-SPN may be an advantageous nutritional support strategy for patients diagnosed with gastric cancer.

Unraveling the complexities of colorectal cancer and its promising therapies - An updated review

Colorectal cancer (CRC) continues to be a global health concern, necessitating further research into its complex biology and innovative treatment approaches. The etiology, pathogenesis, diagnosis, and treatment of colorectal cancer are summarized in this thorough review along with recent developments. The multifactorial nature of colorectal cancer is examined, including genetic predispositions, environmental factors, and lifestyle decisions. The focus is on deciphering the complex interactions between signaling pathways such as Wnt/β-catenin, MAPK, TGF-β as well as PI3K/AKT that participate in the onset, growth, and metastasis of CRC. There is a discussion of various diagnostic modalities that span from traditional colonoscopy to sophisticated molecular techniques like liquid biopsy and radiomics, emphasizing their functions in early identification, prognostication, and treatment stratification. The potential of artificial intelligence as well as machine learning algorithms in improving accuracy as well as efficiency in colorectal cancer diagnosis and management is also explored. Regarding therapy, the review provides a thorough overview of well-known treatments like radiation, chemotherapy, and surgery as well as delves into the newly-emerging areas of targeted therapies as well as immunotherapies. Immune checkpoint inhibitors as well as other molecularly targeted treatments, such as anti-epidermal growth factor receptor (anti-EGFR) as well as anti-vascular endothelial growth factor (anti-VEGF) monoclonal antibodies, show promise in improving the prognosis of colorectal cancer patients, in particular, those suffering from metastatic disease. This review focuses on giving readers a thorough understanding of colorectal cancer by considering its complexities, the present status of treatment, and potential future paths for therapeutic interventions. Through unraveling the intricate web of this disease, we can develop a more tailored and effective approach to treating CRC.

Ultrasound guided-transabdominal plane block (UG-TAPB) reduces pain, opioid consumption and PONV, and is associated with faster recovery for patients undergoing bariatric surgery: a retrospective analysis in a high-volume Italian center

Ultrasound-guided Transversus Abdominis Plane Block (UG-TAPB) reduces post-operative pain better than i.v. painkillers in patients operated with laparoscopic surgery. This study aims to compare the postoperative course of patients undergoing bariatric surgery treated with UG-TABP to that of patients treated with standard analgesic therapy. We retrospectively analyzed patients who have undergone bariatric surgery from November 2021 to April 2023, comparing patients treated with UG-TAPB (Group A) with patients treated with standard i.v. analgesic therapy (Group B). Post-operative numeric-pain rating scale (NRS), nausea and vomiting (PONV), opioid and antiemetic consumption were compared between the two groups until postoperative day (POD) 2. 41 patients underwent bariatric surgery in the aforementioned period. 11 patients were included in group A, whereas 30 patients were included in group B. The two groups were homogeneous for age, BMI, surgery type and comorbidities. Females were more common in Group B (64% vs. 80%; p = 0.019). NRS was significantly lower in Group A than Group B from POD0 to POD2 (3.8 ± 1.2 vs. 6.1 ± 2; p = 0.001 and 1.1 ± 0.3 vs. 3.1 ± 1.3; p < 0.001 after surgery and on POD2 8 pm, respectively). On POD 0, opioid consumption (9% vs. 57%; p = 0.011 and 9% vs. 47%; p = 0.033 after surgery and at 8 pm, respectively), PONV (27% vs. 90%; p < 0.001 and 9% vs. 57%; p = 0.011) and antiemetic consumption (36% vs. 90%; p = 0.001 and 9% vs. 53%; p = 0.014) were higher in Group B. Patients in Group A can be discharged earlier than patients in Group B (1.45 ± 0.82 vs. 2.67 ± 1.39 days; p = 0.005). UG-TAPB is associated with a better and faster recovery after bariatric surgery and should be considered in ERABS.

Effect of home-based exercise prehabilitation on postoperative outcomes in colorectal cancer surgery: a systematic review and meta-analysis

PURPOSE

Home-based exercise training may improve access to surgical prehabilitation in colorectal cancer (CRC) patients, but its efficacy remains unclear. This study systematically investigated the effects of home-based exercise prehabilitation on postoperative exercise capacity, complications, length of hospital stay, and health-related quality of life (HRQoL) in CRC patients.

METHODS

Randomized controlled trials (RCTs) comparing home-based exercise prehabilitation with control in CRC patients were eligible. We searched MEDLINE, Scopus, Web of Science, PEDro, and SPORTDiscus from their inception to June 3, 2024. Methodological quality was assessed using the PEDro scale, and certainty of evidence was assessed using GRADE. Data were synthesized using random-effects meta-analyses, with sensitivity analysis on studies with good methodological quality (PEDro score ≥ 6).

RESULTS

Eight RCTs involving 1092 participants were included. The primary analysis showed a significant improvement in postoperative 6-min walk distance following home-based exercise prehabilitation compared to control (mean difference (MD) = 30.62: 95% CI: [2.94; 57.79]; low-certainty evidence). However, sensitivity analysis revealed no significant between-group differences (MD = 22.60: 95% CI: [- 6.27; 51.46]). No significant effects of home-based exercise prehabilitation were found on postoperative complications (risk ratio = 1.00: 95% CI: [- 0.78; 1.29]; moderate-certainty evidence), length of hospital stay (MD = - 0.20: 95% CI: [- 0.65; 0.23]; moderate-certainty evidence), and HRQoL (physical functioning: MD = 2.62: 95% CI: [- 6.16; 11.39]; mental functioning: MD = 1.35: 95% CI: [- 6.95; 9.65]; low and very-low certainty evidence).

CONCLUSION

Home-based exercise prehabilitation does not reduce postoperative complications and length of hospital stay after CRC surgery. Its effects on postoperative exercise capacity and HRQoL remain uncertain due to low-quality evidence.

Exploring the experiences of patients who receive nutrition education for ostomy care: A qualitative research design

BACKGROUND

Ileostomy and colostomy patients benefit from more nutrition education than patients who receive bowel resections without ostomy creation. Nutrition can influence the adaptation to a stoma and may help manage complications. The impact of nutrition education on health outcomes is known, but a gap exists for the type and timing of nutrition information for patients with newly formed ostomies.

METHODS

A survey of open-ended and closed-ended questions was designed to evaluate experiences about nutrition education provided for living with an ostomy. The survey was conducted during hospital admission for ostomy reversal: 39 patients were approached, 36 consented, and all 36 completed the survey.

RESULTS

Of the 36 patients who took part in the study, 20 (56%) were male. The mean age was 57.7 years. Twenty-four (67%) patients were admitted for an ileostomy reversal and 12 (33%) patients for a colostomy reversal. When patients were asked about their preferred timing of nutrition education, 28% (n = 10) wanted information before surgery, 58% (n = 21) wanted the information in the hospital when admitted for ostomy creation, and 14% (n = 5) wanted to receive it after discharge. A total of 25% (n = 9) of patients commented on the need for a follow-up phone call after discharge to ask questions.

CONCLUSION

Nutrition education is valuable for patients, and most patients want to receive nutrition information while in the hospital. A follow-up session with a dietitian after discharge could assist patients in developing strategies to manage weight changes, prevent dehydration, and lower the risk of malnutrition.

Comparison of early postoperative recovery in patients undergoing elective colorectal surgery before and after ERAS® implementation-a single center three-armed cohort study

PURPOSE

This study examines the impact of enhanced recovery after surgery (ERAS®) on patient recovery after elective colorectal surgery. The innovative PostopQRS™ tool was used for the analysis of patient recovery.

METHODS

This single-center study compares three cohorts: two retrospective cohorts before (A) and after (B) ERAS® implementation and a prospective cohort post-ERAS® implementation (C) using PostopQRS™. The present study was prospectively registered in the German Register of Clinical Trials (DRKS00026903).

RESULTS

A total of 153 patients were included from June 2020 to February 2022. Significant differences were observed in bowel function, oral food intake, opioid use, and PONV (postoperative nausea and vomiting) occurrence. By the day of discharge, 98% in cohorts B and C had bowel movements or stoma output, compared to 66% in cohort A (p < 0.001). Solid food intake on POD1 was higher in cohorts B and C (p = 0.025), while opioid use was lower (p = 0.003 and p < 0.001). Cohort C showed 90% recovery on discharge.

CONCLUSION

This study demonstrates improved early mobility, reduced need for opioids, a higher rate of patients with solid food intake on POD1, and earlier bowel movement as well as excellent recovery following the colorectal ERAS® implementation.

Bowel preparation before elective right colectomy: Multitreatment machine-learning analysis on 2,617 patients

BACKGROUND

In the worldwide, real-life setting, some candidates for right colectomy still receive no bowel preparation, some receive oral antibiotics alone, some receive mechanical bowel preparation alone, and some receive mechanical bowel preparation with oral antibiotics, with varying degrees of compliance to preoperative intravenous antibiotic prophylaxis. Previous studies mainly focused on left-sided colorectal anastomoses while less attention has been devoted to right-sided ileocolic anastomoses. When high-level evidence from randomized clinical trials is lacking, multiple-treatment propensity score weighting analysis of prospective data on the basis of generalized boosted model is superior to a simple propensity score-matching analysis and to an inverse probability weighting in terms of external validity and bias reduction.

METHODS

This is an analysis on the basis of machine-learning procedures of 2,617 patients who underwent elective right colectomies.

RESULTS

The risk of surgical-site infections (5.0% after no bowel preparation) was significantly lower after mechanical bowel preparation with oral antibiotics (4.0%, P = .017), significantly greater after mechanical bowel preparation alone (8.6%, P = .019), and comparable after oral antibiotics alone (3.9%). The risk of anastomotic leakage (3.2% after no bowel preparation) was significantly greater after oral antibiotics alone (4.8%, P = .013). Concerning secondary outcomes, no significant differences were recorded for the risk of overall morbidity and reoperation. The risk of readmission (3.0% after no bowel preparation) was significantly reduced after mechanical bowel preparation with oral antibiotics (1.5%, P = .046), and the risk of major morbidity (5.1% after no bowel preparation) was significantly greater after oral antibiotics alone (6.7%, P = .007).

CONCLUSION

This multitreatment machine-learning analysis, despite some limitations, showed that mechanical bowel preparation with oral antibiotics is associated with a decrease in surgical-site infections after elective right colectomy compared with no bowel preparation.

Implementation of modified enhanced recovery after surgery (ERAS) following surgery for abdominal trauma; Assessment of feasibility and outcomes: A randomized controlled trial (RCT)

BACKGROUND

Enhanced recovery after surgery(ERAS) is a set of multiple perioperative care component not a rigid protocol with improved outcomes for elective surgeries. This study aimed to assess the feasibility and outcomes in trauma patients undergoing laparotomy.

STUDY DESIGN

Prospective single-centre randomized controlled trial(RCT). Patients undergoing emergency laparotomy following trauma were randomized into ERAS(early removal of catheters, early mobilization and initiation of diet, use of opioid-sparing multimodal analgesia) and conventional care groups 24 ​h post-surgery. Outcome measures included length of hospitalization(LOH), recovery of bowel function, duration of removal of catheters and 30-day complications(Clavien-Dindo).

RESULTS

Fifty patients were randomized into ERAS(n ​= ​25) and conventional care(n ​= ​25) groups. Ninety-two percent of patients were young males, 58 ​% had blunt trauma to the abdomen and the most common indication of surgery was hollow viscus injury(88 ​%). ERAS group had a reduced median LOH(days) (6 versus 8, p ​= ​0.007), early recovery of bowel function(p ​= ​0.010) and shorter times for nasogastric tube(p ​= ​0.001), urinary catheter(p ​= ​0.007) and drain(p ​= ​0.006) removal. The complications were comparable in both groups except for deep surgical site infection[significantly lower in ERAS group(p ​= ​0.009)].

CONCLUSION

ERAS is safe and significantly reduces LOH in select trauma patients undergoing laparotomy.

Use of opioids and opioid alternatives during general anesthesia: a pan-Canadian survey among anesthesiologists

PURPOSE

While there is limited patient-centred evidence (i.e., evidence that is important for patients and end-users) to inform the use of pharmacologic opioid minimization strategies (i.e., the use of opioid alternatives) for adult surgical patients requiring general anesthesia, such strategies are increasingly being adopted into practice. Our objectives were to describe anesthesiologists' beliefs regarding intraoperative opioid minimizing strategies use and utility, and to explore important clinical decision-making factors.

METHODS

We conducted a pan-Canadian web-based survey of anesthesiologists that was distributed using a modified Dillman technique. Our multidisciplinary team, including a patient partners panel, participated in the process of domains and items generation, items reduction, formatting, and composition. Our sampling frames were members of the Canadian Anesthesiologists' Society and members of the Association des Anesthésiologistes du Québec. We used the newsletters of each organization to distribute our survey, which was available in English and French and housed on the LimeSurvey (LimeSurvey GmbH, Hamburg, Germany) platform.

RESULTS

From our eligible sampling frame, 18% completed the survey (356 respondents out of 2,008 eligible participants). Most of the respondents believed that using opioid minimization strategies during general anesthesia could improve postoperative clinical outcomes, including pain control (84% agree or strongly agree, n = 344/409). Reported use of pharmacologic opioid minimization strategies was variable; however, most respondents believed that nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate receptor antagonists (ketamine), α2-adrenoceptor agonists (dexmedetomidine), corticosteroids, and intravenous lidocaine improve prostoperative clinical outcomes. The primary factors guiding decision-making regarding the use of opioid minimization strategies were postoperative acute pain intensity, the impact of acute pain on functioning, patient well-being (i.e., quality of recovery) and patient satisfaction with care. A lack of evidence was the most important barrier limiting the use of opioid minimization strategies.

CONCLUSION

In our survey of Canadian anesthesiologists, several opioid minimization strategies were believed to be effective complements to general anesthesia, although there was substantial variation in their reported use. Future randomized controlled trials and systematic reviews evaluating the effectiveness of opioid minimization strategies should prioritize patient-centred outcome measures assessment such as the quality of recovery or the impact of acute pain on functioning.

Non-invasive vagus nerve stimulation to reduce ileus after colorectal surgery: randomized feasibility trial and efficacy assessment (IDEAL Stage 2B)

AIM

Ileus is characterized by a period of intestinal dysmotility after surgery, leading to vomiting and constipation. In preclinical models, vagus nerve stimulation reduces intestinal inflammation and prevents smooth muscle dysfunction, accelerating the return of gut function. This study explored the feasibility of a definitive trial of non-invasive vagus nerve stimulation (nVNS) along with an early assessment of efficacy.

METHOD

A multicentre, randomized feasibility trial (IDEAL Stage 2B) of self-administered nVNS was performed. Patients undergoing colorectal surgery were randomized to nVNS or sham before and after surgery. Feasibility outcomes comprised assessments of recruitment, compliance, blinding and attrition. Clinical outcomes were measures of intestinal function and adverse events. All participants were followed up for 30 days. Interviews with patients and health professionals explored barriers to feasibility and perspectives around implementation.

RESULTS

In all, 125 patients were approached about the study and 97 (77.6%) took part. Across all randomized groups, the median compliance to treatment was 19 out of 20 stimulations (interquartile range 17-20). The incidence of adverse events was similar across groups. In this unpowered feasibility study, the time taken for the return of gut function (such as first passage of stool) was similar between nVNS and sham treatments. According to interviews, patients were highly motivated to use the device because it provided them with an opportunity to engage actively in their care. Health professionals were highly driven to tackle the problem of ileus.

CONCLUSION

Powered assessments of clinical efficacy are required to confirm or refute the promise of nVNS, as already demonstrated in preclinical models. This feasibility study concludes that a definitive randomized assessment of the clinical benefits of nVNS is desired and feasible.

Effect of Multimodal Prehabilitation on Muscle Mass in Rectal Cancer Patients Receiving Neoadjuvant Treatment

Colorectal cancer is the second most prevalent type of cancer in the world. Surgical complications occur in up to 50% of patients which results in increased morbidity, mortality, and poor health-related quality of life. The negative impact on survival and physical function is exacerbated in those receiving neoadjuvant treatment. Prehabilitation offers a more effective approach to ameliorate both the physical and psychological factors important for recuperation and to address sarcopenia. Our study aimed to assess the effect of multimodal prehabilitation on muscle mass in rectal cancer patients receiving neoadjuvant treatment. This is a prospective observational study conducted in a tertiary care gastrointestinal surgical unit. All consecutive patients with locally advanced resectable rectal cancer who received standard long-course neoadjuvant therapy were given a multimodal home-based prehabilitation protocol, and their muscle mass calculated on imaging before surgery was compared with a historical cohort which comprised patients who had not received prehabilitation. A total of 100 patients were enrolled in the study-44 intervention and 56 historical cohort. There was a mean percentage increase in muscle mass in the intervention group, while there was a mean percentage decrease in the historical cohort group. Improved muscle mass was significantly associated with earlier functioning of stoma, earlier tolerance to soft diet, and less surgical site infections. The overall complications, 30-day readmissions, and 30-day emergency visits were less in the prehabilitation group. Prehabilitation has a definite role in improving the physiological status of patients and potentially correlates into better postoperative outcomes. Prehabilitation must be included in management guidelines and be started from the first outpatient visit itself.

Cardiac coherence and medical hypnosis: a feasibility study of a new combined approach for managing preoperative anxiety in patients with breast or gynaecological cancer

Background

Non-pharmaceutical approaches can help manage preoperative anxiety, but few studies have evaluated psychoeducational programmes, especially for cancer surgery. We assessed the feasibility of the COHErence Cardiaque (COHEC) programme where cardiac coherence and medical hypnosis are combined to manage preoperative anxiety in patients undergoing breast or gynaecological cancer surgical interventions (BGCSI).

Methods

Patients undergoing BGCSI were enrolled and followed a daily home programme with cardiac coherence and medical hypnosis sessions, starting 7 days before the procedure. The primary endpoint was optimal patient adherence (i.e. completion of ≥14 sessions). Secondary endpoints were anxiety levels, measured using the Visual Analogue Scale (VAS) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS), satisfaction (EVAN-G), and quality of postoperative recovery (QoR-15).

Results

In total, 53 patients [mean age: 55 (34-82) yr] were included; 83.7% had breast cancer and 15.1% had gynaecological cancer. Optimal adherence was achieved by 64.2% (95% confidence interval: 49.8-76.9%) of the intention-to-treat population. Among the 43 patients who completed at least one session, exploratory analysis showed that anxiety on the day before (P=0.02) and the morning of the intervention (P=0.04) was decreased in patients with severe anxiety at baseline (VAS ≥70). The median VAS satisfaction score for the programme was 10 (4-10). Overall, 94% of patients were willing to include the COHEC programme in their daily routine.

Conclusions

The implementation of a psychoeducational programme combining cardiac coherence and medical hypnosis is feasible and might potentially help patients undergoing BGCSI to manage preoperative anxiety. A randomised trial is underway to assess the efficacy of the COHEC programme.

Clinical trial registration

NCT03981731.

Clinical impact of multidisciplinary team management on postoperative short-term outcomes in colorectral cancer surgery

The multidisciplinary team (MDT) approach has become the standard for perioperative patient care. At our institution, a multidisciplinary perioperative care team called "Surgical, Nutrition and Rehabilitation Integrated Services for Excellence Team (SUNRISE)" was established for all patients with gastrointestinal cancer undergoing surgery. This study aimed to elucidate the significance of SUNRISE as a perioperative MDT by comparing short-term postoperative outcomes before and after the introduction of SUNRISE in patients with colorectal cancer. We included 181 patients diagnosed with colorectal who underwent radical surgical resection with regional lymphadenectomy. The patients were divided into two groups: the pre-SUNRISE group, consisting of 105 patients who underwent radical colorectal surgery before the introduction of the SUNRISE, and the SUNRISE group, consisting of 76 patients who underwent radical colorectal surgery after the introduction of the SUNRISE. We compared the short-term postoperative outcomes between these two groups and analyzed the risk factors affecting postoperative complications using logistic regression models. The incidence of postoperative complications in the SUNRISE group was significantly lower than that in the pre-SUNRISE group (22.4% vs. 41.0%, p = 0.011). Multivariate analysis identified the presence of SUNRISE (odds ratio, 0.33, 95% confidence interval, 0.15-0.73, p < 0.006) as an independent risk factor for postoperative complications. The median postoperative hospital stay in the SUNRISE group was significantly shorter than that in the pre-SUNRISE group (9 vs. 11 days, p < 0.01). The MDT approach is useful for optimizing preoperative patient care and improving short-term postoperative outcomes in patients with colorectal cancer.

Effects of enteral immunonutrition in laparoscopic versus open resections in colorectal cancer surgery: A meta-analysis of randomised controlled trials

INTRODUCTION

Immunonutrition (IMN) modulates the activity of the immune system. However, the effects of IMN on cancer patients following colorectal surgery is still lacking. We performed a systematic review and meta-analysis to evaluate the outcomes of IMN in patients undergoing laparoscopic versus open colorectal surgery.

METHODS

A systematic search of multiple electronic data sources was conducted in accordance with PRISMA guidelines and included MEDLINE via PubMed, EMBASE, Scopus, and Web of Science. All eligible studies reporting comparative outcomes of immunonutrition in colorectal surgery were included. Subgroup analysis of outcomes of interest was performed and data were analysed using Review Manager (RevMan) Version 5.4.1.

RESULTS

Nine randomised controlled trials (RCTs) were identified. The final pooled analysis included 1199 patients (592 IMN group and 592 control group). Of these, 55.3 % (655/1184) had open colorectal surgery (OG) and 44.7 % (529/1184) underwent laparoscopic colorectal surgery (LG). IMN reduced the risk of wound infection significantly in the OG [risk ratio (RR) 0.48, 95 % confidence interval (CI) 0.32 to 0.72; p = 0.0005)] and the open and laparoscopic group (OLG) [RR 0.33, 95 % CI 0.15 to 0.76; p = 0.008]. Moreover, IMN was also associated with a significantly shorter length of hospital stay (MD - 2.37 days, 95 % CI - 3.39 to -1.36; p < 0.0001) in the OG. Other post-operative morbidities (anastomotic leak and ileus) and mortality outcomes in the OG, LG, and OLG were comparable.

CONCLUSIONS

Pre-operative IMN could reduce the wound infection rate and shorten length of hospital stay in patients following elective colorectal surgery. The benefit of these improved clinical outcomes could be further evaluated with a cost-benefit analysis. IMN should be recommended as nutritional adjunct in the Enhanced Recovery after Surgery (ERAS) pathway following colorectal surgery.

Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial

Importance

Evidence suggests that prophylactic abdominal drainage after gastrectomy for cancer may reduce postoperative morbidity and hospital stay but this evidence comes from small studies with a high risk of bias. Further research is needed to determine whether drains safely meet their primary purpose of identifying and managing postoperative intraperitoneal collections without the need for reoperation or additional percutaneous drainage.

Objective

To determine whether avoiding routine abdominal drainage increased postoperative invasive procedures.

Design, Setting, and Participants

The Abdominal Drain in Gastrectomy (ADIGE) Trial was a multicenter prospective randomized noninferiority trial. Enrollment spanned from December 2019 to January 2023. Follow-up evaluations were completed at 30 and 90 days. Eleven centers within the Italian Research Group for Gastric Cancer, encompassing both academic medical centers and community hospitals, were included. Patients with gastric cancer undergoing subtotal or total gastrectomy with curative intent were eligible, excluding those younger than 18 years, with serious comorbidities, or undergoing procedure types outside the scope of the study. Of 803 patients assessed for eligibility, 404 were randomized and 390 were included in final analyses.

Interventions

Patients were randomized 1:1 into prophylactic drain or no drain arms.

Main Outcomes and Measures

The primary end point was a modified intention-to-treat (mITT) analysis measuring reoperation or percutaneous drainage within 30 postoperative days. The null hypothesis was rejected when the 90% CI upper limit of the proportion difference did not exceed 3.56%. The calculated sample size to achieve 80% power with a 10% dropout rate was 404 patients (202 in each group). Surgeons and patients were blinded until gastrointestinal reconstruction.

Results

Of the 404 patients randomized 226 (57.8%) were male; the median (IQR) age was 71 (62-78) years. Intraoperative identification of nonresectable disease occurred in 14 patients, leading to their exclusion from the study, leaving 390 patients. In the mITT analysis, 15 patients (7.7%) in the drain group needed reoperation or percutaneous drainage by postoperative day 30 vs 29 (15%) in the no drain group, favoring the drain group (difference, 7.2%; 90% CI, 2.1-12.4; P = .02). Of note, the difference in the primary composite end point was entirely due to a similar difference in reoperation (5.1% in the drain group vs 12.4% in the no drain group; P = .01). Drain-related complications occurred in 4 patients.

Conclusions and Relevance

The findings of this study indicate that refraining from prophylactic drain use after gastrectomy heightened the risk of postoperative invasive procedures, discouraging its avoidance. Future studies identifying high-risk groups could optimize prophylactic drainage decisions.

Trial Registration

ClinicalTrials.gov Identifier: NCT04227951.

Does Cold Vapor Prevent Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy? A Randomized Controlled Trial

PURPOSE

The aim of this study was to examine the effect of cold vapor on nausea and vomiting in the early postoperative period after laparoscopic cholecystectomy.

DESIGN

Randomized controlled study.

METHODS

This study was carried out with 44 intervention and 44 control group patients who underwent laparoscopic cholecystectomy between May 2022 and December 2022. Cold vapor was applied to the experimental group for 15 minutes in the postanesthesia care unit (PACU). The patients were evaluated in terms of nausea and vomiting at the 0th minute and 30th minute in the PACU, and at the 2nd, 6th, 12th, and 24th hours in service after surgery.

FINDINGS

There was a significant difference between the groups in terms of nausea at the postoperative 30th minute, 2nd hour, and 6th hour. The postoperative nausea incidence and scores in the experimental group were significantly lower. There was no significant difference between the groups in terms of vomiting at all times after surgery.

CONCLUSIONS

Postoperative cold vapor helps to reduce the severity of nausea but does not affect vomiting. Thus, it can be used in the control of nausea after cholecystectomy.

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.

Impact of Early Oral Feeding on Postoperative Outcomes after Elective Colorectal Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

This study aimed to evaluate the influence of early oral feeding (EOF), a key component of enhanced recovery after surgery protocols, on postoperative outcomes in patients undergoing elective colorectal surgery.

METHODS

We searched the MEDLINE, Embase, Cochrane Library, and KoreaMed databases to include randomized clinical trials comparing EOF that started on postoperative day 1 and conventional oral feeding that commenced after first flatus. Two authors independently screened the retrieved records and extracted data. The primary outcome was total complications. Data were pooled, and the overall effect size was calculated using a fixed-effect model.

RESULTS

We screened 13 studies, and 1,556 patients were included in the analysis. The EOF group exhibited fewer total complications (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.38-0.65). Anastomotic leakage was also reduced in the EOF group (OR: 0.40; 95% CI: 0.19-0.83); however, an increased incidence of vomiting (OR: 1.58; 95% CI: 1.11-2.26) as well as a tendency of higher rate of nasogastric tube reinsertion (OR: 1.49; 95% CI: 0.96-2.31) were observed. The EOF group demonstrated a decreased time to flatus (mean difference [MD] -0.87; 95% CI: -1.00 to -0.74) and shortened hospital stay (MD: -0.76; 95% CI: -0.89 to -0.6). No significant difference in mortality was observed between the two groups (OR: 0.54; 95% CI: 0.15-2.01).

CONCLUSION

EOF proved to be a safe and effective practice for patients undergoing elective colorectal surgery. However, the increased incidence of vomiting necessitates careful consideration.

Use and Effectiveness of Carboximaltose Iron in Preoperative Anemia Treatment: A Multicenter and Retrospective Study

Aim

Anemia, primarily due to iron deficiency, is a key risk factor in both elective and emergency surgeries. Immediate preoperative treatment with ferric carboxymaltose (FCM) in anemic patients can reduce the need for transfusions and the length of hospital stay, thereby optimizing surgical outcomes. The objective of this study was to assess the effectiveness and describe the use of administering intravenous FCM prior to elective scheduled surgery for patients diagnosed with anemia.

Methods

Multicenter, retrospective cohort study that encompassed patients aged 18 years and older who underwent surgery between January 2017 and December 2018. Demographic variables, dose scheme, baseline and perioperative haemoglobin (Hb), transfusion requirements, and admission days were collected. The primary endpoints were the response rate and effectiveness of FCM, defined as the proportion of patients with Hb preoperative levels of ≥13 g/dL. A patient response was deemed to occur when Hb level increased by 1 g/dL or more. The secondary endpoints were the appropriateness of FCM dose, transfusion requirement rate, and length of hospital stay.

Results

446 patients (55.2% women, median age 69 IQR:52-78 years) were included. The median total dose of FCM administered was 1000 mg over a span of 5 day (IQR: 0-16) days before surgery. 62.8% of patients received lower doses, 24.9% had an INCREASE of Hb ≥ 1 g/dL, 11.6% had Hb ≥ 13 g/dL and 21.3% required blood transfusions, with a mean of 0.73 units transfused. The length of the hospital stay was 12 days (IQR:6-23).

Conclusion

Low percentage of patients achieved a hemoglobin level of 13 g/dL or experienced an increase in hemoglobin of 1 g/dL or more following the administration of FCM, indicating the low effectiveness of FCM in treating perioperative anaemia in our surgical patients. There is underdosing of FCM and insufficient time between FCM administration and surgery in most patients. Both transfused and non-transfused patients show similar Hb increases, while those receiving a standard 1000 mg dose of FCM experience shorter hospital stays compared to those receiving 500 mg, and patients with more transfusions have longer hospital stays.

Intravenous versus oral iron supplementation for iron deficiency anemia in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy: a study protocol for a randomized controlled trial

BACKGROUND

Numerous studies have been conducted to manage anemia in surgical patients through iron supplementation as an alternative to blood transfusion. However, patients with locally advanced rectal cancer have often been excluded from these studies, due to their standard treatment involving neoadjuvant chemoradiotherapy. This study aims to evaluate the impact of intravenous versus oral iron supplementation on iron deficiency anemia in patients with rectal cancer receiving preoperative chemoradiotherapy.

METHODS

This open-label, single-center, parallel, superiority, randomized trial includes patients with primary rectal cancer who are candidates for preoperative chemoradiotherapy and have confirmed iron-deficiency anemia. A total of 94 patients will be randomly assigned in a 1:1 ratio to receive either intravenous or oral iron supplementation. Stratification factors include age (> 70 vs. ≤ 70 years) and baseline serum hemoglobin levels (7-10 g/dL vs. 10-13 g/dL). The primary endpoint is the percentage of patients achieving normalized hemoglobin levels from the start of treatment to the day of admission for surgery. Secondary endpoints include changes in serum hemoglobin from baseline to postoperatively, changes in iron assay parameters, time needed to hemoglobin normalization, volume of blood transfusions required, and incidence of postoperative complications.

DISCUSSION

This study is the first randomized controlled trial investigating the effect of iron supplementation in iron-deficient patients with rectal cancer undergoing neoadjuvant chemoradiotherapy. This trial is expected to provide evidence for the benefits of administering iron supplementation in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS) of Republic of Korea, KCT0009260, Registered on March 21, 2024.

Consensus in ERAS protocols for ventral hernia repair: evidence-based recommendations from the ACHQC QI Committee

PURPOSE

Enhanced recovery after surgery (ERAS) protocols are widely used in the post-operative care of hernia patients. Despite their prevalence, an absence of published consensus guidelines creates significant heterogeneity in practices. The aim of this study was to evaluate elements in ERAS protocols utilized in ventral hernia repair from institutions across the United States and provide consensus recommendations for each identified element.

METHODS

Institutional members of the Abdominal Core Health Quality Collaborative (ACHQC) Quality Improvement (QI) committee submitted current ERAS protocols. Items within each protocol were classified as "elements", then assigned a topic. Any topic with ≥ 2 elements from separate institutions were labeled as a "theme," then grouped by stage in the patient care cycle. A brief review of current evidence was provided in addition to a ACHQC QI committee consensus statement.

RESULTS

A total of 295 elements from 6 tertiary referral centers specializing in hernia care were compiled into 24 themes and grouped by four separate stages: Pre-Admission Optimization, Pre-Operative Care, Intra-operative Care, and Post-Operative Management.

CONCLUSION

This article represents a multi-institutional review of ERAS protocols for ventral hernia repair and identifies common themes that may provide the framework for a unified ERAS protocol in hernia surgery. Future work may serve to develop societal guidelines defined specifically for enhanced recovery in ventral hernia repair.

Transversus abdominis plane block in minimally invasive colon surgery: a multicenter three-arm randomized controlled superiority and non-inferiority clinical trial

BACKGROUND AND OBJECTIVES

The transversus abdominis plane (TAP) block is the most widely used abdominal field block in colorectal surgery with a postoperative enhanced recovery pathway. We aimed to determine whether the laparoscopic-assisted and ultrasound-guided TAP (US-TAP) blocks provide superior pain relief compared with placebo. We separately investigated whether the laparoscopic-assisted technique was non-inferior to the ultrasound-guided technique in providing pain relief, with a non-inferiority margin of 10 mg morphine dose equivalents.

METHODS

340 patients undergoing elective minimally invasive colon surgery were randomly allocated to one of three groups: (1) US-TAP block, (2) laparoscopic-assisted TAP (L-TAP) block, or (3) placebo. Superiority and non-inferiority were tested for the primary outcome: 24-hour postoperative morphine equivalent consumption. Secondary outcomes, including patient-reported quality of recovery, were included in the superiority analysis.

RESULTS

127 patients were included in each block group and 86 in the placebo group. The US-TAP block was no different from placebo at -1.4 mg morphine (97.5% CI -6.8 to 4.0 mg; p=0.55). The L-TAP block was superior to placebo at -5.9 mg morphine (97.5% CI -11.3 to -0.5 mg; p=0.01) and non-inferior to the US-TAP block at -4.5 mg morphine (98.75% CI -10.0 to 1.1 mg).

CONCLUSION

The L-TAP block was superior to placebo and non-inferior to the US-TAP block. However, neither met our predetermined estimate of the minimal clinically important difference of 10 mg morphine.

TRIAL REGISTRATION NUMBER

NCT04311099.

An interdisciplinary multicentre study on the use of Enhanced Recovery After Surgery protocol in colorectal surgery from Turkiye

BACKGROUND

This study aims to determine the use of surgical nurses, general surgeons, and anaesthesiologists regarding the implementation of Enhanced Recovery After Surgery (ERAS) protocol in colorectal surgery and the barriers to its implementation.

METHOD

This descriptive study was conducted with three different professionals (surgical nurses, surgeons, anaesthesiologists) in four different hospitals and 268 healthcare professionals who voluntarily participated in the study and had written consent were included in the research sample. Data were collected between March 2020-July 2021 via Personal Information Form and Evaluation Form of ERAS Protocol in Colorectal Surgery.

RESULTS

In the study, 57.8 % were nurses, 15.7 % were general surgeons and 26.5 % were anaesthesiologists. It was observed that 73.1 % of the participants hadn't heard of the ERAS Protocol before, and eight participants who answered the application of the ERAS Protocol steps in colorectal surgery in their clinics answered as "Yes". It was determined that very few of the participants correctly knew and/or implemented the recommendations of the ERAS protocol (preoperative, intraoperative and postoperative stages) in colorectal surgery. In addition, the participants reported the obstacles to the implementation of protocol steps as the lack of knowledge (18.1 %), the problems caused by the multidisciplinary work (16.6 %), the resistance to change (12.4 %), and the lack of institutional support (11.4 %).

CONCLUSION

It has been determined that the ERAS Protocol in colorectal surgery is not known enough by health professionals, information and opinions are not compatible with the protocol recommendations, and the barriers to implementation are multifactorial.

Improving Enhanced Recovery after Surgery (ERAS): The Effect of a Patient-Centred Mobile Application and an Activity Tracker on Patient Engagement in Colorectal Surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) protocol improved perioperative colorectal care. Although the protocol is firmly implemented across hospital settings, there are benefits to gain by actively involving patients in their recovery. The main objective of this study was to investigate whether compliance with selected items in the ERAS protocol could further improve by using a patient-centred mobile application.

METHOD

This multicentre, randomised controlled trial was conducted between October 2019 and September 2022. Patients aged 18 years or older who underwent elective colorectal surgery, and in possession of a smartphone were included. The intervention group used a mobile application combined with an activity tracker to be guided and supported through the ERAS pathway. The control group received standard care and wore an activity tracker to monitor their daily activities. The primary outcome was overall compliance with selected active elements of the ERAS protocol.

RESULTS

In total, 140 participants were randomised to either the intervention (n = 72) or control group (n = 68). The use of the ERAS App demonstrated a significant improvement in overall compliance by 10%, particularly in early solid food intake by 42% and early mobilization by 27%. Postoperative or patient reported outcomes did not differ between groups.

CONCLUSION

The smartphone application 'ERAS App' is able to improve adherence to the active elements of the ERAS protocol for colorectal surgery. This is an important step towards optimizing perioperative care for colorectal surgery patients and enabling patients to optimize being in control of their own recovery. Trial registration: ERAS APPtimize, NTR7314 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON29410).

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perioperative Enhanced Recovery Concepts Significantly Improve Postoperative Outcome in Patients with Crohn`s Disease

BACKGROUND AND AIMS

Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s disease [CD], postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking.

METHODS

In a prospective, single-centre study, all patients receiving ileocaecal resection due to CD between 2020 and 2023 were included. A specific, perioperative, enhanced recovery concept [ERC] was implemented and patients were divided into two groups [before and after implementation]. The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index [CCI], secondary endpoints were severe complications, length of hospital stay, and rates of re-admission.

RESULTS

Of 83 patients analysed, 33 patients participated in the enhanced recovery programme [post-ERC]. Whereas patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications [CCI: 21.4 versus 8.4, p = 0.0036; Clavien Dindo > 2: 38% versus 3.1%, p = 0.0002]. Additionally, post-ERC-patients were ready earlier for discharge [5 days versus 6.5 days, p = 0.001] and rates of re-admission were significantly lower [3.1% versus 20%, p = 0.03]. In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications [p = 0.019].

CONCLUSION

A specific, perioperative, enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s disease.

Adherence to enhanced recovery after surgery (ERAS) in older adults following colorectal resection

INTRODUCTION

Enhanced recovery after surgery (ERAS) is an established pathway to improve short-term outcomes in colorectal surgery. It is unclear whether the efficacy, feasibility, and safety of the ERAS protocol are similar in older and younger patients. The study examined adherence to the ERAS protocol and identified factors leading to deviations in older patients.

MATERIALS AND METHODS

Patients undergoing colorectal resection were prospectively included in the ERAS protocol between 2019 and 2022. The cohort was stratified according to age and ERAS adherence score. The patients were compared regarding clinical short-term follow-up (30 days). Univariate and multivariate analyses were performed using the statistical program R (version 4.1.2).

RESULTS

During the study period, 414 patients were recruited, including 132 patients (31.9 %) aged ≥75 years. The cohort of older adults showed significantly higher American Society of Anesthesiologists (ASA) scores III/IV (57.8 % vs. 81.8 %; p < 0.001) and more frequently malignant diseases (45.9 % vs. 64.1 %; p < 0.001), but a lower body mass index (26.7 vs. 24.4; p < 0.001). Furthermore, older adults achieved significantly lower adherence to the ERAS protocol in the postoperative phase (84.6 % vs. 80.1 %; p = 0.003) and experienced a longer median length of hospital stay (6 vs. 8 days; p < 0.001). The differences identified were increased change of body weight on postoperative day 1, delayed removal of a urinary catheter, and shorter duration of mobilization on postoperative days 2 and 3 (p < 0.05). However, in the multivariate analysis, emergency and open surgery as well as severe complications, but not age, were elicited as independent predictive factors for lower adherence to the ERAS protocol postoperatively.

DISCUSSION

Adherence to the postoperative ERAS requirements appears to be lower in older patients, although age alone was not an independent factor in our multivariate analysis and therefore not responsible for a lower adherence to the postoperative ERAS protocol after colorectal resection. This difference underlines the importance of interdisciplinary teamwork in daily practice to achieve optimal postoperative results, especially in older adults.

Effects of neuromuscular block reversal with neostigmine/glycopyrrolate versus sugammadex on bowel motility recovery after laparoscopic colorectal surgery: A randomized controlled trial

STUDY OBJECTIVE

To compare the effects of neostigmine/glycopyrrolate (a traditional agent) and sugammadex on bowel motility recovery and the occurrence of digestive system complications after colorectal surgery.

DESIGN

Prospective, randomized controlled trial.

SETTING

A single tertiary center.

PATIENTS

111 patients undergoing laparoscopic colorectal surgery.

INTERVENTIONS

Patients were randomized into two groups based on the block reversal agent: 1) a mixture of 50 μg.kg-1 of neostigmine and 10 μg.kg-1 of glycopyrrolate (neostigmine group) and 2) 2 mg.kg-1 of sugammadex (sugammadex group).

MEASUREMENTS

The primary outcome was the time from the surgery's completion to the first flatus. The time to the first postoperative defecation, incidences of postoperative nausea or vomiting, ileus, and dry mouth, as well as postoperative length of stay, were also assessed.

MAIN RESULTS

The time to the first flatus was significantly shorter in the sugammadex group than in the neostigmine group (59 [42-79] h vs 69 [53-90] h, P = 0.027). The time to the first defecation and the incidences of postoperative nausea or vomiting and ileus did not differ between the groups, nor did the postoperative length of stay. However, the incidence of postoperative dry mouth was significantly lower in the sugammadex group than in the neostigmine group (7 patients [13%] vs 39 patients [71%], P < 0.001).

CONCLUSIONS

The time to the first flatus was shorter using 2 mg.kg-1 sugammadex to reverse the neuromuscular block for laparoscopic colorectal surgery compared to reversal with conventional neostigmine/glycopyrrolate.

Enhanced recovery after fetal spina bifida surgery: global practice

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients.

METHODS

In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20.

RESULTS

The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume.

CONCLUSIONS

The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A systematic review and meta-analysis of high-quality randomized controlled trials on the role of prehabilitation programs in colorectal surgery

BACKGROUND

Prehabilitation is gaining popularity in colorectal surgery but lacks high-quality postoperative outcomes data. This meta-analysis explored whether prehabilitation impacts postoperative outcomes.

METHODS

In this meta-analysis, compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses, we searched PubMed and Scopus through November 2022. High-quality randomized control trials involving adults who underwent colorectal surgery with/without exercise-based prehabilitation were included. The main outcomes were short-term postoperative morbidity, readmissions, and length of stay. Random-effect meta-analyses were performed, and statistical heterogeneity was assessed using the I2 statistic.

RESULTS

Seven high-quality randomized control trials comprising 1,225 patients were included. The median prehabilitation duration was 4 (2-4) weeks. Four studies compared prehabilitation and standard of care, and 3 compared prehabilitation and rehabilitation. Exercise-based prehabilitation did not reduce the odds of short-term complications (odds ratio 0.62, 95% confidence interval 0.27-1.40, P = .25, I2 = 68%) or readmission (odds ratio 1, 95% confidence interval 0.73-1.46, P = .85, I2 = 0%). The prehabilitation group had shorter length of hospital stay (weighted mean difference -0.2, 95% confidence interval -0.25 to -0.14, P < .0001, I2 = 43.3%). Prehabilitation and rehabilitation had similar odds of short-term complications (odds ratio 1.03, 95% confidence interval 0.56-1.89, P = .91, I2 = 33%), length of stay (weighted mean difference -0.16, 95% confidence interval -0.47 to 0.16, P = .33, I2 = 59%), and readmission (odds ratio 1.25, 95% confidence interval 0.28-5.56, P = .77, I2 = 52%). The only benefit of prehabilitation over rehabilitation was better 6-minute walking distance test results at time of surgery (weighted mean difference: -9.4 m; 95% confidence interval -18.04 to 0.79, P = .03, I2 = 42%).

CONCLUSION

Prehabilitation provided decreased postoperative length of hospital stay and improved preoperative functional outcomes, but not reduced odds of complications and/or readmissions. Prehabilitation and rehabilitation had similar clinical outcomes.

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

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

Thoracic Segmental Anesthesia for Major Laparoscopic Abdominal Surgery in a Heart Transplant Recipient: A Case Report

We describe the case of a 72-year-old male suffering from Marfan syndrome, who, because of cardiac abnormalities correlated to the syndrome, received an orthotopic heart transplant four years ago. In 2024, he was diagnosed with right colon cancer. The decision to operate was difficult because of the elevated perioperative risk. Focused on the possible cardiologic and respiratory complications, we decided to proceed with neuraxial anesthesia during spontaneous breathing. This emergent anesthesiological strategy for open and laparoscopic abdominal surgery has the potential to abolish many risks related to general anesthesia. Right laparoscopic hemicolectomy was successfully performed, and no medical or surgical complications occurred in the postoperative period.

[Prognostic value of body composition in oncological visceral surgery]

Screening of nutritional status of cancer patients plays a crucial role in the perioperative management and is mandatory for the certification of oncological centers by the German Cancer Society (DKG). The available screening tools do not differentiate between muscle and adipose tissue. Recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) as well as the automatic picture archiving communication system (PACS) imaging analysis by high performance reconstruction systems have recently enabled a detailed analysis of adipose tissue and muscle quality. Rapidly growing evidence shows that body composition parameters, especially reduced muscle mass, are associated with adverse outcomes in cancer patients and have been reported to negatively affect overall survival (OS), disease-free survival (DFS), toxicity associated with chemotherapy and surgical complications. In this article, we summarize the recent literature and present the clinical influence of body composition in oncological visceral diseases.

Omission of intraoperative drain placement during robotic partial nephrectomy and robotic radical prostatectomy is safe: an analysis of 18,000 patients

PURPOSE

Placement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications.

METHODS

The NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication.

RESULTS

We identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (β -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62-0.87]), infectious complication (OR 0.66 [0.49-0.89]), and LOS (β -0.30 [-0.37, -0.24]).

CONCLUSIONS

Using a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures.

Effect of multimodal opioid-sparing anesthesia on intestinal function and prognosis of elderly patients with hypertension after colorectal cancer surgery

PURPOSE

Colorectal cancer (CRC) surgery in elderly patients with hypertension poses challenges due to potential complications and prolonged recovery. This study aimed to assess the impact of multimodal opioid-sparing anesthesia on intestinal function and prognosis of elderly hypertension patients undergoing CRC surgery.

METHODS

A total of 80 elderly hypertension patients who underwent open surgery for CRC in the People's Hospital of Xinjiang Uygur Autonomous Region from October 2020 to October 2022 were selected and randomly divided into two group (A and B, n = 40) through the random number table method. Group A received multimodal opioid-sparing anesthesia, defined as low-dose opioid general anesthesia combined with a transversus abdominis plane block, incision infiltration with local anesthetics, and postoperative analgesia via a patient-controlled analgesia (PCA) pump, with the remifentanil dose set at one-third (± 10%) of the conventional group's dose. Group B received conventional opioid anesthesia, involving standard general anesthesia maintained with remifentanil at 0.4-0.5 µg/(kg·min), incision infiltration with local anesthetics, and postoperative PCA. Primary outcomes included mean arterial pressure (MAP) and heart rate (HR), changes in albumin, C-reactive protein (CRP) and white blood cell (WBC), indicators of intestinal function recovery (the recovery time of bowel sounds, the first exhaust time, the first defecation time and the feeding recovery time), and visual analogue scale (VAS) pain scores. Second outcomes included postoperative complications and total hospital stays.

RESULTS

After excluding 8 patients, 72 were included in the final analysis. Compared with patients in the B group, patients in the A group exhibited shorter recovery time of bowel sounds, first exhaust time and feeding recovery time (P < 0.05), higher levels of postoperative albumin, and lower levels of CRP and WBC (P < 0.05). Moreover, the incidence of nausea and vomiting was lower and the total hospital stays were fewer in the A group than in the B group (P < 0.05).

CONCLUSION

Multimodal opioid-sparing anesthesia contributes to rapid recovery of postoperative intestinal function and reduction of postoperative adverse reactions. Therefore, it is safe and feasible to apply multimodal opioid-sparing anesthesia to elderly hypertension patients receiving open surgery for CRC.

Impact of robotic surgery on postoperative gastrointestinal dysfunction following minimally invasive colorectal surgery: incidence, risk factors, and short-term outcomes

AIM

Postoperative gastrointestinal dysfunction (POGD) is a common complication following colorectal surgery. This study aimed to investigate the incidence and risk factors of POGD after minimally invasive surgery and to assess the relationship between robotic surgery, POGD, and their outcomes.

METHOD

Patients who had undergone minimally invasive colorectal surgery at our institution between July 2018 and November 2023 were retrospectively enrolled. POGD was diagnosed based on the presence of two or more intestinal symptoms within 72 h or more after surgery. Risk factors were identified through regression analyses, and the impact of POGD on outcomes was assessed using linear regression.The association between those factors was assessed using subgroup analysis and hierarchical regression.

RESULTS

A total of 226 patients were included in the analysis, including 33 with POGD. POGD occurred in 14.6% of patients, with a lower incidence in robotic surgery (7.3%) than in laparoscopic surgery (19.8%). Multivariate analysis indicated that robotic surgery had a protective effect, while blood loss exceeding 50 ml was an independent risk factor for POGD. POGD was also correlated with longer length of stays and higher costs. The association between POGD, length of stay, and cost varied depending on the surgical platform. Robotic surgery exacerbated the effect of POGD on short-term outcomes, which aligned with the observed significant interaction effect.

CONCLUSION

POGD remains a prevalent postoperative disease. Preventive strategies, including meticulous hemostasis techniques and robotic surgery, should be prioritized by healthcare professionals to reduce POGD risk, improve short-term outcomes, and preserve healthcare resources.