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

Lidocaine-A Promising Candidate for the Treatment of Cancer-Induced Bone Pain: A Narrative Review

Pain is one of the most common symptoms in patients with cancer, with cancer-induced bone pain (CIBP) significantly affecting their quality of life. Opioids are commonly used as first-line treatments for cancer pain, but their use requires caution due to non-mechanistic analgesia and significant side effects. As a result, there is a need for new non-opioid drugs that target cancer pain through specific mechanisms. Recent studies on the anticancer effects of lidocaine have highlighted its potential benefits in both treating cancer and alleviating cancer-induced pain. This article discusses the mechanism of action and clinical applications of lidocaine in cancer pain management, and suggests new treatment approaches for patients with CIBP.

[Epidural anesthesia in thoracic and abdominal surgery : Current perspectives and practical implications]

With the rise of minimally invasive and robot-assisted surgical techniques, the role of epidural anesthesia (EA) in modern practice necessitates careful re-evaluation. This review explores the relevance of EA in thoracic and abdominal surgery, examining its practical applications, residual indications and considerations for its use. Additionally, alternative pain management strategies, including systemic analgesia, regional nerve blocks and novel perioperative approaches, are assessed for advantages and limitations compared to EA.Traditionally the gold standard for perioperative pain control in thoracic and abdominal procedures, EA provides superior analgesia, reduced pulmonary complications and promotes early postoperative mobilization; however, the shift towards less invasive types of surgery has raised questions about the necessity and risk-benefit profile of EA. Complications such as hypotension, hematoma and rare neurological injuries emphasize the importance of thorough risk assessment.Emerging data show that alternative methods, such as transversus abdominis plane (TAP) blocks, paravertebral blocks and multimodal analgesia provide comparable efficacy in specific patient groups while often demonstrating a better safety profile. Nevertheless, EA remains essential in extensive thoracic surgery, complex abdominal resections and in patients with a high risk for severe postoperative pain or respiratory compromise. Combining EA with enhanced recovery after surgery (ERAS) protocols has also shown promise in improving outcomes.In conclusion, while minimally invasive surgical techniques have transformed perioperative care, EA retains a critical role in selected indications. Individualized planning of anesthesia, weighing EA against evolving alternatives and tailored to surgical and patient-specific factors, is essential. This review highlights the integration of evidence-based strategies to optimize the role of EA in contemporary surgical treatment.

A multimodal prehabilitation class for Enhanced Recovery After Surgery: a pragmatic randomised type 1 hybrid effectiveness-implementation trial

BACKGROUND

Prehabilitation promotes postoperative recovery through preoperative optimisation; however, few studies have been conducted under real-world conditions. Our objective was to determine the extent to which a multimodal prehabilitation programme influenced intermediate and late recovery post-colorectal surgery in a type 1 effectiveness-implementation and randomised pragmatic trial. We hypothesised that a prehabilitation class, as part of an Enhanced Recovery After Surgery (ERAS) pathway, would reduce length of hospital stay (LOS).

METHODS

Adult male and female patients with colorectal disease requiring an elective primary resection at a single centre were randomised to the intervention or standard care group at least 2 weeks before surgery. All participants attended an ERAS class, which was extended to include prehabilitation components of nutrition education, supplements, walking with a smartwatch, functional exercises, and deep breathing in the intervention group. Effectiveness outcomes included LOS (primary) and 6-min walking distance (6MWD; secondary outcome) at 6 weeks post-surgery. Implementation outcomes included adherence to prescribed step count and nutrient intakes. Multivariable regression analyses were adjusted for age, sex, type of surgery, and COVID-19.

RESULTS

The study ended prematurely. In total, 110 patients were included. Two-thirds had cancer and mean prehabilitation duration was 17.2 (sd 5.5) days. LOS was not different between groups. Preoperative median step count did not differ between groups, but protein inadequacy (prevalence ratio: 0.59 [95% CI: 0.36-0.82]) decreased substantially with prehabilitation. After surgery, the mean difference in 6MWD was +38 m (95% CI: 9-67 m) for prehabilitation vs control, indicating earlier functional recovery.

CONCLUSIONS

A pragmatic prehabilitation programme did not influence length of hospital stay (underpowered because of early trial termination), but did reduce preoperative protein inadequacy (implementation outcome) and improve early functional recovery (secondary outcome).

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT04247776).

Variation in perioperative practice in elective colorectal cancer surgery: opportunities for quality improvement

BACKGROUND

Understanding the variation in perioperative care across a population is fundamental to improving the management and outcomes of patients with colorectal cancer. Currently, there is limited individual patient level data available to assess this variation. Therefore, as part of an improvement programme, we conducted an audit to understand perioperative care.

METHODS

Audit items were developed to cover the pre, intra and postoperative phases of the colorectal cancer surgical pathway and collected for patients undergoing an elective procedure. The audit was conducted at 14 Hospital Trusts, participating in the Yorkshire Cancer Research Bowel Cancer Improvement Programme, located in the Yorkshire and Humber region, North of England.

RESULTS

Information on 216 patients were collected. Functional assessment by Cardiopulmonary Exercise Testing varied across the region (performed in 100% patients at three Trusts, but not at all in six Trusts, P < 0.001). The provision of postoperative high dependency and critical care also varied across the region (in seven Trusts ≥ 80% of patients went to a monitored bed or higher level of care; in three Trusts ≥ 90% of patients received ward care, P < 0.001). The median duration of preoperative starvation varied by Trust (2 to 13 h, P < 0.001). The intraoperative dose of opiate administered to patients varied significantly between Trusts (P < 0.001).

CONCLUSIONS

There is wide variation in both the provision and practice of perioperative care across a large region in the North of England. The findings are informing a programme of improvement science-based work to improve the management and outcomes of patients with colorectal cancer.

Effect of Enhanced Surgical Recovery Program for Thoracolumbar Spine Surgery on Opioid Use, Length of Hospital Stay, and Hospital Readmissions: Evaluation of 51,236 Cases

BACKGROUND CONTEXT

Evidence-based enhanced surgical recovery (ESR) programs integrate a multidimensional approach to optimize patients during the pre-, intra-, and post-operative phases of surgery. Smaller studies suggest several benefits of spine surgery ESR; this study evaluates the effects of ESR for thoracolumbar (TL) fusion surgery on a national scale.

PURPOSE

Determine if ESR is associated with a reduction in daily morphine milligram equivalents (MME), length of hospital stay (LOS), and 30-day readmission (READMIT) rates compared to non-ESR controls.

STUDY DESIGN

Multicenter, retrospective, case-control study of a prospectively adopted healthcare system ESR program from October 2018 to December 2021.

PATIENT SAMPLE

Consecutive adult patients undergoing TL fusion with known ESR participation status and without a primary diagnosis of tumor, infection, or trauma were included.

OUTCOMES MEASURES

Primary outcomes include daily MME, LOS, and 30-day READMIT rates. Outcomes were analyzed for single-level, multi-level, and all TL fusions.

METHODS

Data from TL fusion procedures performed within a large healthcare system were extracted from hospital-based electronic medical records derived from 1352 surgeons within 138 facilities. Patients were divided as ESR (cases) or non-ESR (controls) based upon enrollment into an ESR program defined by (1) preoperative patient education, (2) multimodal analgesia, (3) intraoperative fluid optimization, (4) opioid-sparing anesthesia, and (5) early postoperative nutrition and ambulation. Outcomes were compared between groups.

RESULTS

Of 51,236 TL fusion cases (45% male, mean age of 63 years), 24,391 participated in an ESR program and 26,845 did not. For single-level TL fusions, ESR was associated with decreased MME (β= -8.76, p<0.001), LOS (β= -8.85, p<0.001), and READMIT (OR=0.77, 95% CI: 0.67-0.88) compared to controls. For multi-level TL fusions, ESR was associated with decreased MME (β= -7.32, p<0.001) and LOS (β= -12.14, p<0.001) compared to controls. For all TL fusions, ESR was associated with decreased MME (β= -7.94, p<0.001), LOS (β= -10.54, p<0.001), and READMIT (OR=0.91, 95% CI: 0.84-0.98) compared to non-ESR controls.

CONCLUSIONS

This national healthcare system analysis of over 50,000 TL spine fusion cases by 1,352 surgeons at 138 centers across the US confirms that ESR adoption is associated with decreased daily MME, LOS, and READMIT compared to non-ESR controls. Surgeons should consider adoption of ESR programs to improve patient care.

Early detection and correction of preoperative anemia in patients undergoing colorectal surgery-a prospective study

INTRODUCTION

Preoperative anemia is an important target in preventing colorectal anastomotic leakage (CAL). However, it is not consistently detected and corrected in patients undergoing colorectal surgery. This study aimed to evaluate the impact of early detection and correction of preoperative anemia on perioperative outcomes and CAL.

METHODS

This was a prospective subanalysis of an international open-labeled trial, which implemented an enhanced care bundle to prevent CAL after elective colorectal surgeries. It introduced interventions for early detection and correction of preoperative anemia. Primary outcome was the incidence of preoperative anemia and the effect of early correction. Secondary outcomes included the impact on CAL, postoperative course, and mortality.

RESULTS

The study included 899 patients across eight European hospitals (September 2021-December 2023). Preoperative anemia was identified in 35.0% (n = 315) of participants, with 77.4% (n = 192) receiving iron therapy. Hemoglobin levels decreased in 4.2% (n = 13), remained stable in 45.8% (n = 143), and increased in 50.0% (n = 156) (p < 0.001). Perioperative hyperglycemia was more common among patients with anemia (7.8% versus 16.4%, p < 0.001). CAL occurred in 6.1% (n = 53) of patients. Anemia correction and changes in hemoglobin levels after iron treatment were not significantly associated with CAL, other complications, or mortality.

CONCLUSIONS

Early detection and correction of preoperative anemia is achievable. However, routine preoperative administration of iron alone, without concurrently optimizing other CAL risk factors, does not result in CAL prevention. Preoperative anemia indicates overall poor physiological fitness rather than being an isolated risk factor.

TRIAL NUMBER

NCT05250882 (20-01-2022).

The Effects of Early Oral Intake in the Postanesthesia Care Unit on Nausea and Vomiting: A Meta-analysis of Randomized Controlled Trials

PURPOSE

This systematic review and meta-analysis aimed to investigate whether early oral fluid intake after surgery compared with delayed oral intake causes nausea and vomiting in pediatric patients who underwent general anesthesia in the postanesthesia care unit (PACU).

DESIGN

Systematic review and meta-analysis.

METHODS

Conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (version 6.4), this study searched electronic databases, including Pubmed, CINAHL, Embase, Cochrane CENTRAL, PubMed, RISS, and KoreaMed up to July 2023. The Risk of Bias 2 tool assessed the risk of bias, and R statistical software facilitated meta-analysis. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

FINDINGS

A meta-analysis of 6 randomized controlled trials (RCTs) (2,723 patients) found early oral intake in the PACU decreased vomiting incidence by 36% compared with delayed oral fluid intake (risk ratio = 0.64, 95% confidence interval: 0.42 to 0.97, P = .040, I2 = 7%) with moderate certainty of evidence. Another meta-analysis of 3 RCTs (2,185 participants) showed that early oral intake did not increase nausea compared with delayed oral intake (95% confidence interval: -0.76 to 0.07, P = .071, I2 = 0%) with low certainty of evidence.

CONCLUSIONS

Early oral fluid intake in the PACU decreases postoperative vomiting without raising nausea. Health care providers should consider implementing early oral fluid intake in the PACU for enhanced recovery of pediatric patients.

Preoperative posterior quadratus lumborum block: determining the minimum effective ropivacaine concentration in 90% of patients (MEC90) for postoperative analgesia after laparoscopic myomectomy

BACKGROUND

Quadratus lumborum block (QLB) has gained traction as a regional anesthesia technique to manage postoperative pain following laparoscopic surgery. However, the 90% minimum effective concentration (MEC90) of local anesthetics for posterior QLB remains undetermined.

METHODS

We conducted a double-blind, comparative dose-finding study involving 54 women scheduled for elective laparoscopic myomectomy under general anesthesia. Each patient received a bilateral posterior QLB with 20 mL of ropivacaine on each side. The concentration administered varied for each patient and was determined based on the response of the previous participant. The initial concentration was set at 0.20%. Upon successful block, the subsequent patient was assigned to receive either the same (probability of 0.89) or a 0.05% lower concentration (probability of 0.11). In cases of block failure, the concentration was increased by 0.05% for the next patient. The trial concluded when 45 successful blocks were achieved, with block success defined as a pain score of three or fewer 30 minutes after arrival in the post-anesthesia care unit.

RESULTS

The 90% minimum effective concentration (MEC90) of ropivacaine was 0.340% (95% CI 0.329 to 0.344%).

CONCLUSIONS

The optimal concentration of ropivacaine for posterior QLB to achieve satisfactory analgesia following laparoscopic myomectomy is a 20 mL volume of 0.340% ropivacaine per side.

REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200055743.

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.

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.

The Effect of Prolonged Fasting Before Surgery on Pain and Anxiety

PURPOSE

To investigate the effect of prolonged fasting before surgery on pain and anxiety.

DESIGN

This was a descriptive study.

METHODS

This study was conducted in a plastic, reconstructive, and esthetic surgery clinic at a university hospital in Bursa, Turkey. A data collection tool was designed to collect data on the sociodemographic characteristics. The Beck Anxiety Scale was used to assess patients' anxiety in the preoperative period and the Visual Analog Scale was used to measure pain levels in the postoperative period. The Statistical Package for Social Sciences was used for data analysis.

FINDINGS

A total of 363 patients took part in the study. A majority (91.2%) of the patients who participated in the study were aware of why they were fasting before surgery, and 41.6% of them had been informed about preoperative fasting by the nurse. In addition, 60.9% of patients had thirst, 17.6% had headache, 40.5% were hungry, 62% had dry mouth, 79.6% were restless, and 83.7% were anxious. Most (82.6%) of the patients who participated in the study had a preoperative fasting period of more than 6 hours, 58.4% had a postoperative fasting period of 5 hours or less, and the mean fasting period was 6.82 ± 1.76. The mean score of the Visual Comparison Scale was 5.09 ± 0.31 and the mean score of the Beck Anxiety Scale was 21.86 ± 0.054, and patients with a fasting period of 6 hours or more experienced more pain and anxiety.

CONCLUSIONS

This study shows that patients with longer fasting duration experience more pain and anxiety, and patients with more anxiety experience more pain. Based on the results of this study, it is recommended that studies should be done to emphasize the issue and to increase the awareness of health care professionals about pre- and postoperative fasting.

Narrative review: nutritional strategies for ageing populations - focusing on dysphagia and geriatric nutritional needs

The increase in elderly populations worldwide highlights the urgency of addressing age-related problems through effective nutritional management to enhance the well-being of the elderly and for the prevention and treatment of various diseases. The trend towards an increasing elderly population brings with it an increase in conditions such as sarcopenia, osteosarcopenia and frailty, emphasising the importance of regular checks for malnutrition in the elderly and the implementation of personalised nutritional therapies. The importance of nutrition in addressing geriatric syndromes such as frailty, sarcopenia, osteosarcopenia, obesity and metabolic syndrome is highlighted. Dysphagia, frequent in the elderly, requires special attention to prevent malnutrition and complications. It is essential to maintain muscle mass and bone health in old age. In this review we investigate the fundamental role of nutrition in geriatrics, focusing on promoting healthy ageing and managing problems such as malnutrition and overeating. The importance of protein intake and healthy dietary patterns such as the Mediterranean diet are then discussed. Finally, the challenges of personalised nutritional care, including the need for artificial nutrition or oral supplements, to improve quality of life and health care in an ageing society are addressed.

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.

Rise in Minimally Invasive Surgery for Colorectal Cancer Is Associated With Adoption of Robotic Surgery

BACKGROUND

Minimally invasive surgery is associated with improved short-term outcomes and similar long-term oncologic outcomes for patients with colorectal cancer compared with open surgery. Although the robotic approach has ergonomic and technical benefits, how it has impacted the utilization of traditional laparoscopic surgery and minimally invasive surgery overall is unclear.

OBJECTIVE

Describe trends in open, robotic, and laparoscopic approaches for colorectal cancer resections and examine factors associated with minimally invasive surgery.

DESIGN

Retrospective cohort study using data from the National Cancer Database from 2010 to 2020.

SETTING

Commission on Cancer-accredited US facilities.

PATIENTS

Patients diagnosed with nonmetastatic colon or rectal adenocarcinoma.

MAIN OUTCOME MEASURES

Surgical approach rates (open, robotic, and laparoscopic).

RESULTS

We identified 475,001 patients diagnosed with nonmetastatic colorectal adenocarcinoma, of whom 192,237 (40.5%) underwent open surgery, 64,945 (13.7%) underwent robotic surgery, and 217,819 (45.9%) underwent laparoscopic surgery. For colon cancer, laparoscopic minimally invasive surgery use steadily increased, with a peak prevalence of 54.0% in 2016, and total minimally invasive surgery (robotic + laparoscopic) was performed more often than open surgery from 2013 through 2020. For rectal cancer, laparoscopic minimally invasive surgery had a peak prevalence of 37.2% in 2014 and declined from 2014 through 2020; robotic surgery prevalence increased throughout the study period (5.5% in 2010, 24.7% in 2015, and 48.8% in 2020). Minimally invasive surgery use increased in facilities performing robotic surgery every year during the study period. For both colon and rectal cancer, the use of open surgery decreased across all facilities throughout the study period.

LIMITATIONS

This study used the National Cancer Database, which may not be generalizable to non-Commission on Cancer institutions.

CONCLUSIONS

Minimally invasive surgery steadily increased across all facilities from 2010 through 2020. Open resections declined, laparoscopic resections plateaued, and robotic resections increased for colon and rectal cancer. Minimally invasive surgery increases may be driven by increases in robot-assisted surgery. See Video Abstract.

EL AUMENTO DE LA CIRUGA MNIMAMENTE INVASIVA PARA EL CNCER COLORRECTAL SE ASOCIA CON LA ADOPCIN A LA CIRUGA ROBTICA

ANTECEDENTES:La cirugía mínimamente invasiva se asocia con mejores resultados a corto plazo y resultados oncológicos similares a largo plazo para pacientes con cáncer colorrectal en comparación con la cirugía abierta. Aunque el abordaje robótico tiene beneficios ergonómicos y técnicos, no está claro cómo ha afectado la utilización de la cirugía laparoscópica tradicional y la cirugía mínimamente invasiva en general.OBJETIVO:Describir las tendencias en los abordajes abiertos, robóticos y laparoscópicos para las resecciones de cáncer colorrectal y examinar los factores asociados con la cirugía mínimamente invasiva.DISEÑO:Estudio de cohorte retrospectivo utilizando datos de la Base de Datos Nacional del Cáncer desde 2010 hasta 2020.ESCENARIO:Centros estadounidenses acreditados por la Comisión sobre el Cáncer.PACIENTES:Pacientes diagnosticados con adenocarcinoma de colon o recto no metastásico.PRINCIPALES MEDIDAS DE VALORACIÓN:Tasas de abordaje quirúrgico (abierto, robótico, laparoscópico).RESULTADOS:Identificamos 475.001 pacientes con diagnóstico de adenocarcinoma colorrectal no metastásico, de los cuales 192.237 (40,5%) se sometieron a cirugía abierta, 64.945 (13,7%) se sometieron a cirugía robótica y 217.819 (45,9%) se sometieron a cirugía laparoscópica. Para el cáncer de colon, el uso de cirugía mínimamente invasiva laparoscópica aumentó de manera constante, con una prevalencia máxima del 54,0% en 2016, y la cirugía mínimamente invasiva total (robótica + laparoscópica) se realizó con mayor frecuencia que la cirugía abierta desde 2013 hasta 2020. Para el cáncer de recto, la cirugía mínimamente invasiva laparoscópica tuvo una prevalencia máxima del 37,2% en 2014 y disminuyó desde 2014 hasta 2020; La prevalencia de la cirugía robótica aumentó durante el período de estudio (5,5 % en 2010, 24,7 % en 2015, 48,8 % en 2020). El uso de cirugía mínimamente invasiva aumentó en los centros que realizan cirugía robótica cada año durante el período de estudio. Tanto para el cáncer de colon como para el cáncer de recto, el uso de cirugía abierta disminuyó en todos los centros durante el período de estudio.LIMITACIONES:Se utilizó la base de datos nacional sobre el cáncer, que puede no ser generalizable a instituciones que no pertenecen a la Comisión sobre el Cáncer.CONCLUSIONES:La cirugía mínimamente invasiva aumentó de manera constante en todos los centros entre 2010 y 2020. Las resecciones abiertas disminuyeron, las resecciones laparoscópicas se estabilizaron y las resecciones robóticas aumentaron para el cáncer de colon y recto. Los aumentos de la cirugía mínimamente invasiva pueden estar impulsados por aumentos en la cirugía asistida por robot. (Traducción--Ingrid Melo ).

How aging may impact the failure to rescue after colorectal laparoscopic surgery. Analysis of 1000 patients in a single high-volume center

This study aimed to evaluate the FTR after laparoscopic colorectal surgery in an Italian high-volume centre. A retrospective analysis was conducted in a consecutive series of patients who underwent elective laparoscopic colorectal surgery for neoplastic disease between January 2010 and December 2023 at the General Surgery Department of the San Eugenio Hospital, Rome, Italy. Patients were grouped by age in adult (vs. < 75 years) and elderly group (≥ 75 years). A multivariate analysis of the predictive factors of complications was performed. A total of 1,000 patients met the inclusion criteria, excluding those who underwent open or robotic surgery, either in emergency or elective settings. 53 patients (5.3%) experienced major complications. The mean age of patients with no or mild complications was 65.60 years (± 10.61), whereas patients with severe complications were older (69.94 years ± 12.02, p = 0.0041). Gender distribution and BMI do not represent a risk factor for major complications (p = 0.2555 and p = 0.2686, respectively), unlike the ASA score III or IV (p = 0.0001). The overall FTR rate for adult patients is 9%, while it is slightly higher at 10% for elderly patients. No statistical differences were found between the 2 groups. Elderly patients had more frequent FTR due to infective complications, while the FTR rate for cardiovascular disease was more frequent in the adult group. Minimally invasive approach, skilled team, well-established rapid response and standardized complication management protocols can positively impact FTR regardless of patients' age.

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.

The effects of psychological intervention on negative emotions, pain, and sleep in patients with advanced colon cancer

OBJECTIVE

To investigate the effectiveness of psychological interventions in improving negative emotions, pain, and sleep quality among patients with advanced colon cancer.

METHODS

From March 2021 to March 2023, a total of 218 patients with advanced colon cancer were selected from the First Affiliated Hospital of Soochow University based on strict inclusion and exclusion criteria. Patients were randomly assigned to either the control group or the observation group (109 patients each) using a random number table. The control group received standard medical care, while the observation group received psychological interventions. Both groups were assessed for anxiety and depression levels [using the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS)], sleep quality [measured by the Pittsburgh Sleep Quality Index (PSQI)], pain intensity [using the Visual Analog Scale (VAS)], and overall quality of life. Inter-group comparisons were conducted.

RESULTS

Post-intervention assessments showed a decrease in SAS and SDS scores for both groups, with the observation group demonstrating a more significant reduction (P < 0.05). Additionally, the observation group reported significantly lower pain levels (VAS scores) and improved sleep quality (PSQI scores) compared to the control group, along with a markedly higher quality of life as measured by the Quality of Life Core Questionnaire (QLQ-30) (P < 0.05).

CONCLUSION

This study demonstrates that psychological interventions effectively alleviate anxiety, depression, pain, and sleep disturbances in patients with advanced colon cancer, thereby improving their overall quality of life. However, further studies are required to explore the long-term impact on prognosis.

Hospital resilience in the Face of Covid-19 in France: A multilevel analysis of the impact of past practice quality on cancer surgery resumption

The COVID-19 pandemic disrupted routine hospital services, causing a substantial backlog of surgeries in 2020. This study investigates hospital resilience in resuming activities during the pandemic, focusing on the impact of pre-pandemic adoption of enhanced recovery after surgery protocols (ERAS) in digestive cancer surgery. ERAS involves patient-centered care protocols proven to improve care process and outcomes but are not systematically implemented in hospitals. We define hospital resilience as the ability to maintain and resume surgery levels in the second half of 2020 during the pandemic. Using French national hospital data for digestive cancer surgeries, we categorized hospitals by the intensity of their ERAS volume before the pandemic and estimated a multilevel model allowing to control for hospital characteristics and pandemic conditions in the area they are situated. Results show that, all else being equal, hospitals that implemented ERAS before the pandemic absorbed the surgical backlog and recovered their pre-pandemic activity level more quickly. High-volume hospitals and specialized cancer centers were also quicker than other hospitals in resuming surgical operations. The findings highlight the differences in care practices across hospitals and the importance of quality protocols in bolstering hospital resilience during health crises. Beyond improving patient outcomes, widespread adoption of such protocols could enhance healthcare resource utilization and help to mitigate broader economic and environmental pressures.

[Colorectal endometriosis surgery: Technical and technological innovations in service of a complex surgery]

INTRODUCTION

Digestive endometriosis represents the most common form of deep endometriosis, significantly impacting patients' quality of life. The optimization of its surgical management has been marked by major technological advances. This review explores the evolution of colorectal endometriosis surgery, highlighting the progress in laparoscopy, the contribution of robotics, the shift towards organ preservation, and the optimization of postoperative care.

METHODS

A systematic literature search was conducted in the PubMed and Embase databases, focusing on clinical studies, meta-analyses, and international guidelines published between 1980 and 2025. Articles were selected based on their relevance to technical advancements and clinical outcomes.

RESULTS

Laparoscopy has replaced laparotomy, leading to a reduction in complications and an improvement in postoperative quality of life. Robotics, while not a groundbreaking revolution, provides advantages in precision and surgeon comfort. Conservative procedures have emerged as safe alternatives to systematic extensive segmental resection. Indication criteria have evolved to favor strategies tailored to the depth and extent of lesions while minimizing complication risks and preserving digestive function and quality of life. The standardization of procedures, the abandonment of systematic protective ileostomy, and enhanced recovery protocols have contributed to reducing surgical morbidity and improving patients' quality of life.

CONCLUSION

Technical and technological advancements have transformed colorectal endometriosis surgery. Surgical strategies are shifting towards personalized approaches, integrating minimally invasive surgery and optimized multidisciplinary management. The future lies in the continuous improvement of techniques and the better standardization of surgical indications.

Usefulness of intraoperative colonoscopy and synchronous scoring system for determining the integrity of the anastomosis in left-sided colectomy: a single-center retrospective cohort study

OBJECTIVES

The aim of this study is to evaluate the utilization of intraoperative colonoscopy (IOC) for determining the integrity of the anastomosis and to establish an IOC scoring system.

METHODS

A retrospective cohort study was conducted from January 2021 to June 2024, we analyzed the clinical data of 160 patients registered in a database who underwent laparoscopic left-sided colectomy at Pusan National University Yangsan Hospital. IOC was performed on all patients, and Mucosal color (MC), stapled line bleeding (BL), proximal redundancy (PR), and bowel preparation (BP) were evaluated and scored as variables. Logistic regression analysis was used to evaluate risk factors for anastomotic leakage (AL) and Cohen's kappa was applied to assess the reproducibility of the evaluation.

RESULTS

Of 160 patients, 10 (6.25%) experienced AL. All the IOC variables had kappa values of 0.8 or higher, indicating good agreement. The logistic regression analysis revealed significant differences in the MC 2 (P = 0.017, OR 12.86), PR 2 (P = 0.001, OR 27.64), BP 2 (p = 0.016, OR 10.50) PR 2 score (P = 0.016, OR 10.50) and the sum of the scores (p = 0.001, OR 3.51).

CONCLUSION

IOC can be performed as a reference procedure to assess the integrity of the anastomosis during left-sided colorectal surgery.

Preoperative Antibiotic Compliance and Colorectal Surgical Site Infection in Children

INTRODUCTION

Surgical site infection (SSI) prevention "bundles" have been shown to reduce rates of SSI in adult colorectal surgery (CRS) patients. Our purpose was to investigate the association between selection and timing of preoperative antibiotics and incidence of SSI in pediatric CRS patients.

METHODS

We performed a retrospective analysis of a prospectively collected cohort study spanning January 2019-December 2022 comparing the incidence of SSI in all pediatric CRS patients at a single institution before and after implementation of a surgical "bundle" focused on appropriate selection and timely administration of prophylactic antibiotics. Antibiotic selection and timing were each categorized compliant or noncompliant. SSIs were stratified into superficial, deep incisional, and organ space infections. The primary outcome was incidence of SSI within 30 d of operation. Logistic regression analysis was performed.

RESULTS

Full compliance was noted in 56% of cases in the prebundle cohort and 88% of cases in the postbundle cohort. SSI rates were decreased by 44%. A logistic regression model failed to identify antibiotic selection or timing as an independent predictor of SSI.

CONCLUSIONS

The implementation of this perioperative surgical bundle was associated with a reduction in superficial SSI in pediatric CRS patients. Notably, specific adherence to antibiotic selection and timing of administration alone were not found to be predictive for reduction in SSI rates. These findings may support the use of surgical bundles in SSI reduction in pediatric patients undergoing CRS.

Pediatric enhanced recovery after surgery (ERAS): Advancements and outcomes in the last 5 years

PURPOSE OF REVIEW

The aim is to describe recent advances in pediatric enhanced recovery after surgery (ERAS) in all phases of care as well as the outcomes and impact of recent evidenced-based pathways in pediatric patients.

RECENT FINDINGS

While profoundly impactful in the care of adult patients for nearly 3 decades, ERAS had a slower start in pediatric care that began approximately 10 years ago. Early outcomes were promising, and the multidisciplinary approach to perioperative care has gained momentum, with recent single-center studies of ERAS for pediatric patients showing reductions in both complications and length of stay. The first ERAS Society recommendations for pediatric patients were published in 2024, and two multicenter trials of pediatric ERAS, Pediatric urology recovery after surgery endeavor and ENhanced Recvovery in CHildren Undergoing Surgery (ENRICH-US), have completed enrollment and are expected to publish results in 2025.

SUMMARY

ERAS in pediatric practice has made great strides in the past 5 years and has led to improved outcomes for young patients. Multicenter trial outcomes and the development of additional rigorous ERAS Society recommendations for children will guide future care.

A Prospective Mixed Methods Study on Experiences of Mindfulness Intervention on Pain and Anxiety in Patients Undergoing a Colorectal Surgery

Purpose: To evaluate the effectiveness and experiences of a mindfulness intervention in colorectal surgical patients. Design of Study: Descriptive mixed methods study. Method: Sixteen participants were provided with two or three 15-20-min mindfulness sessions. Data were collected before and after each session on blood pressure, heart and respiratory rate, anxiety, and pain. The participants were interviewed before their discharge. Findings: Eight participants (n = 8) received two and eight (n = 8) three sessions. Decreasing blood pressure and lower heart rates were noted after the sessions. Also, decreasing pain scores were found, especially in participants who attended two sessions. Minor decrease in anxiety scores were noticed in participants who attended three sessions. Two major themes emerged from the interviews: healing and restoration of health and becoming in tune with self. These themes were characterized by study participants' reflections on experience of recovery, progression to physical relaxation, pathway to serenity, awareness of emotions, evolution of perceptions and experiences of mindfulness. Conclusions: The physiological changes to mindfulness intervention, composed of two or three sessions, were minor and challenging to measure to demonstrate effects. However, study participants' experiences were very positive and suggest that this intervention could prove to be beneficial for colorectal surgical patients.

Factors predicting lower hospital stay after liver transplantation using a comprehensive enhanced recovery after surgery (ERAS) protocol

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols facilitate patient recovery without increasing complication rates. An ERAS protocol designed for our liver transplant (LT) patients obtained a median hospital length of stay (LOS) of 4 days. However, a proportion of patients do not achieve early discharge. This study aimed to identify factors that predict an LOS≤ 4 days.

METHODS

Identifying factors associated with LOS <4 days in our LT patients.

RESULTS

We performed 293 LTs (2012-2021), LOS≤4 days in 171 (58.4 %). The following factors emerged as statistically predictors of LOS≤4 days in the univariate analysis: male sex, HCC or HCV patients, lower MELD score, lower BAR score, no DCD patients, shorter operative time, no intraoperative transfusion, shorter ICU stay, no Clavien-Dindo complications grade ≥ III, no primary graft dysfunction, no acute rejection, no readmission at 30 days and no retransplantation were associated to LOS≤4 days. However, in the multivariate analysis, the only independent risk factor that predicted LOS≤4 days was the presence of hepatocarcinoma. DCD donors and higher MELD score were negative factors.

CONCLUSIONS

Applying ERAS programs in LT patients is beneficial, safe and extensible to all patients, but those with hepatocarcinoma obtain higher rates of LOS≤4 days.

Pain, opioid consumption, and epidural anesthesia in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy: an observational cohort study

BACKGROUND

Surgery is often needed to provide disease control in patients with inflammatory bowel disease. Studies document increased postoperative pain and complicated perioperative courses. This study examines postoperative pain and opioid consumption in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy. Furthermore, the impact of epidural anesthesia is investigated.

METHODS

This study encompassed an observational cohort of patients with inflammatory bowel disease undergoing subtotal colectomy in the period 1 January 2018 to 30 June 2023 at a university hospital in Denmark. Demographic and perioperative data, opioid consumption, pain scores, and procedural data of epidural anesthesia were retrieved from patient records. Data were stratified according to the use of epidural anesthesia.

RESULTS

The study included 153 patients. Overall, 45% of patients received epidural anesthesia. Opioid consumption in the postoperative care unit was 9.2 mg (3.3-15.8 mg) and 3.8 mg (0-15 mg) (P = 0.04) in patients without and with epidural anesthesia, respectively. Correspondingly, opioid consumption during the first 24 h postoperatively was 23.3 mg (10-33 mg) and 6.8 mg (0-21.7 mg) (P < 0.001). Numerical rating scale (NRS) pain in the postoperative care unit was 3.5 (2-4.6) and 2.7 (1.3-4.3) in patients without and with epidural anesthesia, respectively (P = 0.1645). Thirty percent of patients treated with epidural anesthesia experienced ≥ 1 adverse event(s) related to epidural anesthesia.

CONCLUSIONS

Our study demonstrates a relatively low consumption of opioids and low pain scores in the early postoperative period following laparoscopic subtotal colectomy regardless of the use of epidural anesthesia. Epidural anesthesia was associated with a substantial frequency of adverse events.

Impact of Preoperative CT-Measured Sarcopenia on Clinical, Pathological, and Oncological Outcomes After Elective Rectal Cancer Surgery

Background: Patients with rectal cancer may be exposed to a loss of muscle strength and quality. This study aimed to assess the role of preoperative CT-based sarcopenia on postoperative clinical, pathological, and oncological outcomes after rectal cancer surgery. Methods: This retrospective monocentric study included patients who underwent elective oncologic resection for rectal adenocarcinoma between 01/2014 and 03/2022. The skeletal muscle index (SMI) was measured using CT at the third lumbar vertebral level, and sarcopenia was defined based on pre-established sex-specific cut-offs. Patients with sarcopenia were compared to those without sarcopenia in terms of outcomes. A Cox proportional hazard regression analysis was used to determine the independent prognostic factors of disease-free survival (DFS) and overall survival (OS). Results: A total of 208 patients were included, and 123 (59%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (66 vs. 61 years, p = 0.003), had lower BMI (24 vs. 28 kg/m2, p < 0.001), and were mainly men (76 vs. 48%, p < 0.001). There was no difference in overall and major complication rates between the sarcopenia and non-sarcopenia group (43 vs. 37%, p = 0.389, and 17 vs. 17%, p = 1.000, respectively). Preoperative and postoperative features related to rectal surgery were comparable. The only predictive factor impacting OS was R1/R2 resection (HR 4.915, 95% CI, 1.141-11.282, p < 0.001), while sarcopenia (HR 2.013, 95% CI 0.972-4.173, p = 0.050) and T3/T4 status (HR 2.108, 95% CI 1.058-4.203, p = 0.034) were independently associated with DFS. Conclusions: A majority of patients undergoing rectal cancer surgery had preoperative CT-based sarcopenia. In this cohort, sarcopenia had no impact on postoperative morbidity and OS but was independently associated with DFS.

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

An Online Preoperative Screening Tool to Optimize Care for Patients Undergoing Cancer Surgery: A Mixed-Method Study Protocol

BACKGROUND/OBJECTIVE

Despite surgery being the primary curative treatment for cancer, patients with compromised preoperative physical, nutritional, and psychological status are often at a higher risk for complications. While various screening tools exist to assess physical, nutritional, and psychological status, there is currently no standardised self-reporting tool, or established cut-off points for comprehensive risk assessment. This study aims to develop, validate, and implement an online self-reporting preoperative screening tool that identifies modifiable risk factors in cancer surgery patients.

METHODS

This mixed-methods study consists of three distinct stages: (1) Development-(i) a scoping review to identify available physical, nutritional, and psychological screening tools; (ii) a Delphi study to gain consensus on the use of available screening tools; and (iii) a development of the online screening tool to determine patients at high risk of postoperative complications. (2) Testing-a prospective cohort study determining the correlation between at-risk patients and postoperative complications. (3) Implementation-the formulation of an implementation policy document considering feasibility.

CONCLUSIONS

The timely identification of high-risk patients, based on their preoperative physical, nutritional, and psychological statuses, would enable referral to targeted interventions. The implementation of a preoperative online screening tool would streamline this identification process while minimising unwarranted variation in preoperative treatment optimisation. This systematic approach would not only support high-risk patients but also allow for more efficient provision of surgery to low-risk patients through effective risk stratification.

The Impact of Enhanced Recovery After Surgery Compliance in Colorectal Surgery for Cancer

Background: This study aimed to assess the impact of Enhanced Recovery After Surgery (ERAS) compliance and to identify which components of this protocol are most likely to affect postoperative outcomes in patients undergoing colorectal cancer surgery. Methods: This is a retrospective cohort evaluating patients who underwent elective colon resection. ERAS compliance was assessed based on adherence to the protocol components. The study examined the following outcomes: postoperative complications, readmission rates, mortality, conversion to open surgery, stoma creation, and length of hospital stay. Results: Of the 410 patients studied, 59% achieved ≥75% compliance. Comparison between compliance groups (<75% versus ≥75%) showed significant differences in overall complications (P = .002), severe complications (P = .001), and length of hospital stay (P < .001). The area under the receiver operating characteristic curve for predicting the absence of severe complications based on ERAS compliance was 0.677 (95% confidence interval: 0.602-0.752). Logistic regression analyses demonstrated that ERAS compliance was significantly associated with a reduced risk of severe complications (P < .001), as well as that the following items: avoiding prophylactic drains (P < .001), minimal use of postoperative opioids (P = .045), avoidance of postoperative salt and water overload (P < .001), postoperative nutritional support (P = .048), and early mobilization (P = .025). Conclusion: High ERAS compliance is associated with improved postoperative outcomes in colorectal cancer surgery. Key protocol components for preventing severe complications include avoiding prophylactic drains, minimal postoperative opioid use, avoiding salt and water overload, nutritional support, and early mobilization.

[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.

Feasibility of an < 24 h discharge pathway with tele-monitoring after elective colectomies: a pilot study

INTRODUCTION

Implementation of enhanced recovery after surgery principles has led to exploration of ambulatory pathways in surgery, including gastrointestinal surgery. However, implementation of ambulatory pathways after colorectal surgery has not been established yet. Previous studies suggest that discharge within 24 h in colorectal surgery is only possible with a clear protocol and careful patient selection.

METHODS

Single center prospective feasibility pilot study of thirty patients in one large non-academic teaching hospital in the Netherlands. Patients were included if they were between 18 and 80 years old, underwent elective minimal invasive colonic resection with anastomosis, had a ASA-score of I or II, fully understood the procedure, had a person at home the first 4 days after surgery and lived within 30 min travel radius to the hospital. Exclusion criteria were cT4 tumours, multi-visceral resections, insulin-dependent diabetes, anti-coagulants which required perioperative bridging, and perioperative complications. Patients followed a pathway with discharge within 24 h postoperatively and were monitored by a tele-monitoring smartphone application after discharge.

RESULTS

Thirty patients were included and twenty-one patients (70%) fulfilled discharge criteria within 24 h after surgery. Six (20%) patients were readmitted within 30 days. Complications occurred in six (20%) patients, which was classified as Clavien-Dindo ≥ 3 complication in one (3%) patient. Patients and health care provider satisfaction was high.

CONCLUSION

Findings of this study support the feasibility and safety of an early discharge protocol with tele-monitoring after minimal invasive colonic resection. Satisfaction of patients and health care providers was high.

Simplified Enhanced Recovery After Surgery Intraoperative Fluid Management

INTRODUCTION

This study evaluates the efficacy of a simplified intraoperative fluid administration metric within enhanced recovery after surgery (ERAS) pathways. The objective is to optimize fluid management to improve postoperative outcomes, specifically kidney function.

METHODS

A retrospective evaluation was conducted at Massachusetts General Hospital on adult patients who underwent open hysterectomy, colectomy, and gastrectomy as part of ERAS pathways. The proposed fluid metric, set at 500 mL/h, was assessed against traditional methods of fluid administration. Data on serum creatinine (Cr) changes as defined as the difference between the baseline value and the maximum value within 1 week of surgery were collected, and compliance with the metric was monitored. Analysis involved Wilcoxon rank-sum test, Kruskal-Wallis test, and quantile regression.

RESULTS

The study included 1028 patients. Regression analysis indicated that compared to patients who received the optimal fluid quantity, those receiving below the optimal range showed an absolute increase in median Cr levels of 0.03 mg/dl (95% confidence interval = -0.005, 0.05) while those who received above the optimal range demonstrated an absolute increase in median Cr level of 0.01 (95% confidence interval = -0.03, 0.05).

CONCLUSIONS

The new fluid metric demonstrated a balanced approach to fluid administration, reducing the risk of overhydration while maintaining sufficient hydration. Additionally, implementing a simplified fluid metric of 500 mL/h in ERAS pathways is effective in improving postoperative kidney function. This approach facilitates adherence to fluid guidelines and can be applied across various healthcare settings. This metric serves as a practical, evidence-based pathway for fluid administration for most patients undergoing most ERAS procedures.

Enhanced Recovery after Surgery - Evidence and Practice

AbstractEnhanced Recovery After Surgery (ERAS) is a global initiative comprised of a series of evidence-based interventions in the preoperative, intraoperative, and postoperative surgical phases. When implemented as a bundle, ERAS interventions both improve clinical outcomes and provide cost savings to the health care system. This review provides an update on the current evidence for individual ERAS elements to improve quality of care as well as practical recommendations for multidisciplinary teams to implement their own ERAS programs.

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.

Feasibility of a Comprehensive eCoach to Support Patients Undergoing Colorectal Surgery: Longitudinal Observational Study

BACKGROUND

The mainstay of colorectal cancer care is surgical resection, which carries a significant risk of complications. Efforts to improve outcomes have recently focused on intensive multimodal prehabilitation programs to better prepare patients for surgery, which make the perioperative process even more complex and demanding for patients. Digital applications (eCoaches) seem promising tools to guide patients during their care journey. We developed a comprehensive eCoach to support, guide, and monitor patients undergoing elective colorectal surgery through the perioperative phase of the care pathway.

OBJECTIVE

The primary aim of this study was to determine its feasibility, in terms of recruitment rate, retention rate, and compliance. Also, usability and patient experience were examined.

METHODS

A single-center cohort study was conducted from April to September 2023 in a tertiary teaching hospital in the Netherlands. All elective colorectal surgery patients were offered an eCoach that provided preoperative coaching of the prehabilitation protocol, guidance by giving timely information, and remote monitoring of postoperative recovery and complications. Recruitment and retention rate, as well as compliance for each part of the care pathway, were determined. Secondary, patient-reported usability measured by the Usefulness, Satisfaction, and Ease of Use questionnaire and patient experiences were reported.

RESULTS

The recruitment rate for the eCoach was 74% (49/66). Main reasons for exclusion were digital illiteracy (n=10), not owning a smartphone (n=3), and the expected burden of use being too high (n=2). The retention rate was 80% (37/46). Median preoperative compliance with required actions in the app was 92% (IQR 87-95), and postoperative compliance was 100% (IQR 100-100). Patient-reported usability was good and patient experiences were mostly positive, although several suggestions for improvement were reported.

CONCLUSIONS

Our results demonstrate the feasibility of a comprehensive eCoach for guiding and monitoring patients undergoing colorectal surgery encompassing the entire perioperative pathway, including prehabilitation and postdischarge monitoring. Compliance was excellent for all phases of the care pathway and recruitment and retention rates were comparable with rates reported in the literature. The study findings provide valuable insights for the further development of the eCoach and highlight the potential of digital health applications in perioperative support.

Nutritional Assessment and Management of Patients with Brain Neoplasms Undergoing Neurosurgery: A Systematic Review

BACKGROUND/AIM

Nutritional management in neurosurgical patients with brain neoplasms is critical, as optimal nutritional status is potentially associated with improved clinical outcomes. This systematic review aimed to analyze the impact of pre- and postoperative nutritional assessment and effect of prepost interventions on the clinical outcomes.

METHODS

A systematic review was conducted using the PubMed, Cochrane Library, Embase, and CINAHL databases, complemented by a search of grey literature. Study quality was assessed using the Joanna Briggs Institute framework, and the certainty of evidence was graded according to the Oxford Centre for Evidence-Based Medicine levels.

RESULTS

Fourteen studies, encompassing a total of 11,224 adult patients with brain neoplasms, were included. Many of these studies were retrospective, had small sample sizes, and examined diverse nutritional protocols. Preoperative nutritional status assessment, including clinical parameters such as albumin (p < 0.001), Controlling Nutritional Status score (p = 0.001), and Prognostic Nutritional Index (p < 0.010), combined with postoperative oral nutritional supplements (p < 0.001), was significantly associated with postoperative clinical outcomes. Additionally, personalized nutritional counseling contributed to a reduction in complications and facilitated more effective functional recovery.

CONCLUSIONS

Nutritional care is vital in managing neurosurgical patients with brain neoplasms, reducing complications and enhancing postoperative recovery and overall clinical outcomes. A multidisciplinary team is key to optimal outcomes. Future research should aim to standardize protocols for broader applicability.

The Effect of Neuromuscular Electrical Stimulation on Muscle Proteolysis, Muscle Mass and Strength, Cardiorespiratory Fitness, Functional Activity, and Quality of Life in Post-Cardiac Surgery Patients: A Narrative Review

Advances in medical and surgical practices, along with enhanced cardiac ICU services, have led to a substantial increase in cardiac surgeries (CS). Consequently, CS is now more frequently performed on older patients undergoing complex procedures, which results in higher rates of postoperative complications (POC) such as muscle proteolysis, prolonged hospital stays and worsened clinical and functional outcomes. These complications can delay early mobilization (EM) programs and exercise as core components of post-CS rehabilitation even though sometimes they fail to prevent functional decline. Neuromuscular electrical stimulation (NMES) has emerged as a physical modality to prevent muscle atrophy, improve muscle strength (MS), and enhance overall functional ability in post-CS patients with physical limitations. Therefore, NMES has been chosen for post-operative patients with physical limitations. This review aimed to describe the effects of NMES on muscle proteolysis, muscle mass (MM) and strength (MS), cardiorespiratory fitness (CRF), functional activity, and quality of life (QoL) in post-CS patients. Data were synthesized from PubMed, Google Scholar, and CINAHL using relevant keywords, and the review included six original articles and one systematic review. Findings indicate that perioperative NMES does not significantly affect proteolysis; however, postoperative NMES appears to increase metabolism and reduce protein degradation, thereby preventing muscle weakness. Although NMES has been shown to enhance MS, its impact on increasing MM remains insignificant. Similarly, improvements in the 6-minute walk distance (6MWD), a measure of CRF, were not statistically significant, even if they were clinically meaningful. Secondary outcomes related to functional activity and QoL also did not show significant improvements. In conclusion, post-operative NMES stimulates protein anabolism and insignificantly improves MS and MM without significantly enhancing CRF as measured by 6MWD. This may explain the lack of significant improvements in functional activity and QoL in post-CS patients.

Postoperative anaemia is associated with poor long term postoperative outcomes after elective colorectal oncologic surgery within an enhanced recovery after surgery pathway

BACKGROUND

Anaemia is an independent risk factor for poor perioperative outcomes after major abdominal surgery, and is associated with an increased risk of 30-day postoperative mortality after noncardiac surgery.

OBJECTIVE

To investigate the frequency of postoperative anaemia and short- and long-term survival after colorectal oncologic surgery at a centre with a well-established Enhanced Recovery After Surgery (ERAS) program.

METHODS

We conducted a retrospective cohort study of all patients undergoing elective colorectal oncologic surgery within an ERAS pathway at our institution between 2013 and 2017. Overall survival was calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at hospital discharge.

RESULTS

A total of 680 patients were included. Patients with anaemia at discharge showed a lower overall survival at 5 years (53.9% vs. 44%, p 0.05). Patients who were anaemic at discharge had a lower 5-year overall survival (hazard ratio [HR] 95% CI 2.663 [1.619-4.379], p < 0.001). Kaplan-Meier survival and Cox regression proportional hazard survival for overall survival in the combined preoperative, postoperative, and RBC transfusion model were 1.55 (1.038 2.318) p = 0.032.

CONCLUSIONS

The combined prognostic value of preoperative anaemia, postoperative anaemia, and blood transfusion created a 40.7% higher risk of not surviving 5 years.

Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Major surgery for gastrointestinal cancer carries a 50% risk of postoperative complications. Physiotherapists commonly provide interventions to patients undergoing gastrointestinal surgery for cancer with the intent of preventing complications and improving recovery. However, the evidence is unclear if physiotherapy is effective compared to providing no physiotherapy, nor if timing of service delivery during the perioperative pathway influences outcomes. The objective of this review is to evaluate and synthesise the evidence examining the effects of perioperative physiotherapy interventions delivered with prophylactic intent on postoperative outcomes compared to no treatment or early mobilisation alone.

METHODS

A protocol was prospectively registered with PROSPERO and a systematic review performed of four databases. Randomised controlled trials examining prophylactic physiotherapy interventions in adults undergoing gastrointestinal surgery for cancer were eligible for inclusion.

RESULTS

Nine publications from eight randomised controlled trials were included with a total sample of 1418 participants. Due to inconsistent reporting of other perioperative complications, meta-analysis of the effect of physiotherapy was only possible specific to postoperative pulmonary complications (PPCs). This found an estimated 59% reduction in risk with exposure to physiotherapy interventions (RR 0.41, 95%CI 0.23 to 0.73, p < 0.001). Sub-group analysis demonstrated that timing of delivery may be important, with physiotherapy delivered only in the preoperative phase or combined with a postoperative service significantly reducing PPC risk (RR 0.32, 95%CI 0.17 to 0.60, p < 0.001) and hospital length of stay (MD-1.4 days, 95%CI -2.24 to -0.58, p = 0.01), whilst the effect of postoperative physiotherapy alone was less certain.

CONCLUSIONS

Preoperative-alone and perioperative physiotherapy is likely to minimise the risk of PPCs in patients undergoing gastrointestinal surgery for cancer. This challenges current traditional paradigms of providing physiotherapy only in the postoperative phase of surgery. A review with broader scope and component network analysis is required to confirm this.

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.

Perioperative enhanced recovery program implementation improves clinical outcomes in patients with ulcerative colitis after total proctocolectomy with ileal pouch-anal anastomosis

BACKGROUND

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely regarded as a definitive surgical option for managing ulcerative colitis (UC). Enhanced recovery programs (ERP) have shown potential in better outcomes following surgery; however, their perioperative benefits in UC patients undergoing IPAA remain insufficiently investigated.

METHODS

This study included UC patients who underwent IPAA between January 2008 and September 2023 across multiple affiliated centers within the China UC Pouch Center Union. Key outcomes analyzed included postoperative complications and long-term quality of life (QOL), assessed via the comprehensive complication index (CCI) and Cleveland Global Quality of Life (CGQL) instrument.

RESULTS

A total of 216 patients were included, with a median follow-up of 8.0 years (interquartile range, 4.0-11.0 years); 62 patients underwent comprehensive ERP. Results indicated that ERP implementation significantly lowered CCI scores (p = 0.036), reduced the incidence of severe complications (CCI > 26.2, p = 0.019), shortened hospital stays (p = 0.046), and improved long-term QOL (p < 0.001). Non-adherence to ERP emerged as an independent risk factor for severe postoperative complications (odds ratio, 3.195; 95% confidence interval, 1.332-7.664; p = 0.009) and impaired QOL (odds ratio, 3.222; 95% confidence interval, 1.462-7.101; p = 0.004).

CONCLUSION

Our study provided supporting evidence for the application of perioperative ERP in a specific homogeneous cohort of UC patients undergoing IPAA to further improve clinical outcomes for them.

Impact of Fascial Plane Block on Postoperative Length of Stay and Opioid Use Among Colectomy Patients Within an Established Enhanced Recovery After Surgery Program: A Retrospective Cohort Study

Background

Use of fascial plane blocks is increasing yet their impact on hospital length of stay (LOS) and opioid use within the context of an enhanced recovery after surgery (ERAS) pathway has been inconclusive. We address this gap by examining the impact of fascial plane blocks on postoperative LOS and opioid use for colorectal surgical procedures in a hospital setting with a robust ERAS program.

Methods

This is a retrospective cohort study using electronic health record data from a large, integrated health care delivery system with an established ERAS program in Northern California. Patients include adults who underwent non-emergent laparoscopic (n=5496) or non-laparoscopic (n=708) colectomy surgery from January 1, 2015 to May 20, 2021. The main exposure was type of anesthesia: general with long-acting fascial plane block, general with short-acting fascial plane block, or general only. Outcomes included postoperative LOS and average daily morphine milligram equivalents (MME) up to three days post-surgery.

Results

Most patients were older than age 50 (86% laparoscopic; 83% non-laparoscopic), female (52% laparoscopic; 58% non-laparoscopic), and non-Hispanic White (64% laparoscopic; 62% non-laparoscopic). In LOS adjusted models for laparoscopic and non-laparoscopic surgery, there was no significant difference for LOS with general with long-acting fascial plane block or with general with short-acting fascial plane block, compared to general only. In MME adjusted models for laparoscopic surgery, general with short-acting fascial plane block was associated with higher MME compared with general only (RE: 1.14,[95% CI: 1.03-1.25], p-value=0.01). However, in non-laparoscopic surgery, general with long-acting fascial plane block was associated with lower MME (RE: 0.63, [95% CI: 0.42-0.93], p-value=0.02), compared with general only.

Conclusion

Fascial plane blocks did not impact postoperative LOS in either surgical group but long acting resulted in lower overall postoperative opioid use for non-laparoscopic 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.

Association of perioperative immunonutrition with anastomotic leak among patients undergoing elective colorectal surgery within a robust enhanced recovery after surgery program

BACKGROUND

Immunonutrition supplementation has been shown to reduce the risk of surgical infectious complications; however, its effect on decreasing anastomotic leak rates, in the context of an otherwise robust Enhanced Recovery After Surgery (ERAS) program, remains unclear. This study aims to assess the association between perioperative immunonutrition supplementation and anastomotic leak in an elective Enhanced Recovery After Surgery colorectal surgical population.

METHODS

We performed a retrospective single-institution cohort study consisting of adult patients enrolled in an Enhanced Recovery After Surgery pathway and undergoing elective colorectal surgery from 2018 to 2023. Immunonutrition supplementation was defined as a 10-day perioperative supply of commercially available nutritional shakes. Relevant demographic covariates, preoperative characteristics, and operative methods were identified and analyzed. Multivariable logistic regression was performed to determine the association of immunonutrition with anastomotic leak.

RESULTS

A total of 708 patients were included in the study, of which n = 400 (56.5%) received perioperative immunonutrition. Patients who received immunonutrition were more likely to be older (median age 57.9 vs 55.7), male (52.7% vs 44.8%), have a higher body mass index (27.7 vs 26.3), and less likely to be current smokers (9.8% vs 16.2%). On adjusted analysis, there was no association between immunonutrition use and anastomotic leak (odds ratio = 0.96, 95% confidence interval = 0.45, 2.08), 30-day readmission (odds ratio = 0.97, 95% confidence interval = 0.60, 1.57), or length of stay (β = .40, 95% confidence interval = -0.06, 0.86) CONCLUSION: We did not observe an association between perioperative immunonutrition supplementation and postoperative anastomotic leak, suggesting that the role of immunonutrition within a comprehensive Enhanced Recovery After Surgery program for elective colorectal surgery may warrant further evaluation.

The impact of indocyanine green fluorescence angiography (ICG-FA) on anastomotic leak rates and postoperative outcomes in colorectal anastomoses: a systematic review

BACKGROUND

Anastomotic leak (AL) is a major complication in colorectal surgery, significantly contributing to perioperative morbidity and mortality. Among strategies to prevent AL, Indocyanine Green Fluorescence Angiography (ICG-FA) has emerged as a promising method for assessing bowel perfusion intraoperatively. This systematic review evaluates the impact of ICG-FA on AL rates and other postoperative outcomes following colorectal anastomoses.

METHODS

A systematic search was conducted in PubMed, PubMed Central, MEDLINE, and Google Scholar, following PRISMA guidelines. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and retrospective cohort studies comparing ICG-FA to controls in adult patients undergoing colorectal resections and anastomoses. Data on AL rates, intraoperative characteristics, and postoperative outcomes were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool.

RESULTS

Sixteen studies (12 retrospective, 1 prospective, and 3 RCTs) involving 3231 patients (1562 ICG-FA and 1669 controls) were included. AL rates were significantly lower in the ICG-FA group (5.18%) compared to controls (11.50%) (p < 0.01). ICG-FA influenced surgical plans in 16.31% of cases. Operative time and ileostomy formation rates were comparable between groups. Reoperation, ileus, and wound infection rates showed minimal differences. Mortality rates were low in both groups (ICG-FA: 0.55%, control: 0.51%).

CONCLUSION

ICG-FA significantly reduces AL rates without increasing operative time or postoperative complications. This technique provides a reliable and safe assessment of bowel perfusion, supporting its integration into colorectal surgery protocols. Further high-quality RCTs are needed to confirm these findings and optimise its application.

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.

SELective defunctioning Stoma Approach in low anterior resection for rectal cancer (SELSA): Protocol for a prospective study with a nested randomized clinical trial investigating stoma-free survival without major LARS following total mesorectal excision

AIM

Accumulated data suggest that routine use of defunctioning stoma in low anterior resection for rectal cancer may cause kidney injury, bowel dysfunction and a higher risk of permanent stomas. We aim to study whether avoidance of a diverting stoma in selected patients is safe and reduces adverse consequences.

METHODS

SELSA is a multicentre international prospective observational study nesting an open-label randomized clinical trial. All patients with primary rectal cancer planned for low anterior resection are eligible. Patients operated with curative intent, aged <80 years, with an American Society of Anaesthesiologists' fitness grade I or II, and a low predicted risk of anastomotic leakage are eligible to 1:1 randomization between no defunctioning stoma (experimental arm) or a defunctioning stoma (control arm). The primary outcome is the composite measure of 2-year stoma-free survival without major low anterior resection syndrome (LARS). Secondary outcomes include anastomotic leakage, postoperative mortality, reinterventions, stoma-related complications, quality of life measures, LARS score, and permanent stoma rate. To be able to state superiority of any study arm regarding the main outcome, with 90% statistical power and assuming 25% attrition, we aim to enrol 212 patients. Patient inclusion will commence in the autumn of 2024.

CONCLUSION

The SELSA study is investigating a tailored approach to defunctioning stoma use in low anterior resection for rectal cancer in relation to the risk of anastomotic leakage. Our hypothesis is that long-term effects will favour the selective approach, enabling some patients to avoid a defunctioning stoma.

TRIAL REGISTRATION

Swedish Ethical Review Authority approval (2023-04347-01, 2024-02418-02 and 2024-03622-02), Regional Ethics Committee Denmark (H-24014463), and ClinicalTrials.gov (NCT06214988).

Enhanced Recovery After Surgery Pathways and Obstetric Anesthesia: A Bibliometric Analysis

As enhanced recovery after surgery (ERAS) pathways are being used exceedingly all over the world, research on ERAS and obstetric anesthesia is expanding. The necessity for uniform guidelines is highlighted by the notable regional and institutional differences in ERAS pathway implementation. Bibliometric research can identify these differences, which promotes a more consistent use of evidence-based procedures. The present bibliographic analysis reviewed 866 documents from the Scopus database using the keywords "enhanced recovery after surgery, ERAS, and Obstetrics Anesthesia." An increased number of articles were added to the database from 2017, with 175 articles in 2024. VOSviewer software (version 1.6.20, Leiden University, Netherlands) was used to investigate the various aspects of bibliometric analysis. The five aspects that were analyzed were co-authorship, co-occurrence, citation, bibliographic coupling, and co-citation. The United States of America had the maximum number of articles, citations, organizations, co-authorship, and co-citation with other authors, organizations, and countries. In the citations category, Gustafsson had the maximum number of citations in documents, and Anesthesia and Analgesia had the maximum number of citations in a journal. A thorough summary of the development of the field of ERAS in obstetric anesthesia can be found in this bibliometric analysis. This analysis has identified important research contributions, significant authors, and new trends by looking at publications, citations, and collaborations. Future research, policymaking, and clinical practice could benefit greatly from this information.