Enhanced recovery after surgery: Current status and future progress

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC

Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery.

HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES

Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Application of enhanced recovery after surgery during the perioperative period in children with Meckel's diverticulum-a single-center prospective clinical trial

Background

Enhanced recovery after surgery (ERAS) has been widely used in adult surgery. However, few studies have reported the efficacy of ERAS in paediatric patients with Meckel's diverticulum (MD), the aim of the study was to prospectively evaluate the safety and efficacy of ERAS in treating MD.

Methods

A prospective randomised controlled study of children with MD admitted to our hospital from Jan 1, 2021 to Dec 31, 2023 were conducted, we developed and implemented an ERAS program for this patients. All cases were strictly selected according to the inclusion and exclusion criteria. Among these patients, they were randomly assigned to the ERAS group or the traditional (TRAD) group with random number table row randomization. The main observational indicators were operation time, intraoperative hemorrhage, FLACC pain scale results on 2 h, 6 h, 12 h, 24 h after surgery, length of postoperative stay (LOPS), time to first defecation, time to first eating after surgery, time to discontinuation of intravenous infusion, total treatment cost, incidence of postoperative complications, 30-day readmission rate and parental satisfaction rate.

Results

A total of 50 patients underwent Meckel's diverticulectomy during this period, 7 patients were excluded, 23 patients were assigned to the ERAS group and 20 patients were assigned to the TRAD group. There were no significant differences in demographic data and operation time, intraoperative hemorrhage. The FLACC pain scale results on 2 h, 6 h, 12 h, 24 h after surgery were significantly lower in the ERAS group. The LOPS was 6.17 ± 0.89 days in the ERAS group and 8.30 ± 1.26 days in the TRAD group, resulting in a significantly shorter LOPS in ERAS group. ERAS could also reduce the first postoperative defecation time, the time to first eating after surgery and the time to discontinuation of intravenous infusion. The treatment cost was decreased in the ERAS group. The rate of complications and 30-day readmission were not significantly different between the two groups.

Conclusions

In this single-center study, the ERAS protocol for patients with MD requiring surgery was safe and effective.

Faster Return to Daily Activities and Better Pain Control: A Prospective Study of Enhanced Recovery After Surgery Protocol in Breast Augmentation

BACKGROUND

Enhanced recovery after surgery (ERAS) has been proven to decrease the amount of opioid use and reduce postoperative pain for a variety of surgeries, including breast reconstruction. However, data on ERAS in breast augmentation is lacking.

OBJECTIVES

This study aims to investigate the effectiveness and safety of ERAS for breast augmentation.

METHODS

A standardized ERAS protocol was established with full consideration of all aspects of perioperative care. Patients undergoing implant-based breast augmentation were prospectively recruited between December 2020 and January 2023, and assigned to either the ERAS or non-ERAS group randomly. The primary outcome was the activity of daily living after surgery. The secondary was postoperative pain and other outcomes included time to freely elevation, vomiting frequency, the use of analgesics, and complications.

RESULTS

A total of 122 patients were included, with 70 in the ERAS group and 52 in the non-ERAS group. Compared to non-ERAS patients, ERAS patients had a shorter time to freely elevation of upper limbs (2.3 d vs. 5.5 d, P < 0.001). For ERAS patients, the pain scores were significantly lower on postoperative days 1 to 3, the activity of daily living index was significantly higher on postoperative days 1 to 3 and the opioids consumption was decreased (7.1 mg vs. 46.2 mg, P = 0.018). No difference was observed in complication and hospital costs between the two groups.

CONCLUSION

The ERAS protocol significantly reduced postoperative pain and the use of opioids and promoted a return to daily activities without increasing complications in breast augmentation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Effect of acupuncture inclusion in the enhanced recovery after surgery protocol on tumor patient gastrointestinal function: a systematic review and meta-analysis of randomized controlled studies

Introduction

Acupuncture has been shown to be effective in restoring gastrointestinal function in tumor patients receiving the enhanced recovery after surgery (ERAS) protocol. The present systematic review and meta-analysis aimed to evaluate the rationality and efficacy of integrating acupuncture in the ERAS strategy to recuperate gastrointestinal function.

Methods

We searched eleven databases for relevant randomized clinical trials (RCTs) of acupuncture for the treatment of gastrointestinal dysfunction in tumor patients treated with the ERAS protocol. The quality of each article was assessed using the Cochrane Collaboration risk of bias criteria and the modified Jadad Scale. As individual symptoms, the primary outcomes were time to postoperative oral food intake, time to first flatus, time to first distension and peristaltic sound recovery time (PSRT). Pain control, adverse events, and acupoint names reported in the included studies were also investigated.

Results

Of the 211 reviewed abstracts, 9 studies (702 patients) met eligibility criteria and were included in the present systematic review and meta‑analysis. Compared to control groups, acupuncture groups showed a significant reduction in time to postoperative oral food intake [standardized mean difference (SMD) = -0.77, 95% confidence interval (CI) -1.18 to -0.35], time to first flatus (SMD=-0.81, 95% CI -1.13 to -0.48), time to first defecation (SMD=-0.91, 95% CI -1.41 to -0.41, PSRT (SMD=-0.92, 95% CI -1.93 to 0.08), and pain intensity (SMD=-0.60, 95% CI -0.83 to -0.37).The Zusanli (ST36) and Shangjuxu (ST37) acupoints were used in eight of the nine included studies. Adverse events related to acupuncture were observed in two studies, and only one case of bruising was reported.

Discussion

The present systematic review and meta‑analysis suggested that acupuncture significantly improves recovery of gastrointestinal function and pain control in tumor patients receiving the ERAS protocol compared to the control group. Moreover, ST36 and ST37 were the most frequently used acupoints. Although the safety of acupuncture was poorly described in the included studies, the available data suggested that acupuncture is a safe treatment with only mild side effects. These findings provide evidence-based recommendations for the inclusion of acupuncture in the ERAS protocol for tumor patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/ PROSPERO, identifier CRD42023430211.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States

BACKGROUND

Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country.

METHODS

Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open).

RESULTS

A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001).

CONCLUSIONS

Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications).

Application of enhanced recovery after surgery in perioperative patients undergoing laparoscopic surgery for gastric cancer: A meta-analysis

BACKGROUND

To analyze the effect of enhanced recovery after surgery (ERAS) in perioperative patients undergoing laparoscopic surgery for gastric cancer (GC).

METHODS

We searched the literature databases of PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://www.webofscience.com/) for studies related to ERAS and laparoscopic surgery for GC from their inception till October 2022, and the retrieved articles were further screened for analysis. The literature quality was evaluated based on the Cochrane risk of bias tool. The endpoints included the first postoperative exhaust time, first postoperative bowel movement, length of stay, complications and hospitalization expenses. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

11 studies were included, involving 2039 patients. Meta-analysis showed that the first postoperative exhaust and bowel movement were earlier and the length of stay was shorter in the experimental group (e.g.,) than in the control group (CG) (P < .05). Moreover, a lower incidence of complications and markedly reduced hospitalization expenses were determined in for example (P < .05). Due to the heterogeneity in the comparison of indicators such as the first postoperative exhaust and bowel movement across articles, a funnel plot was drawn for observations. The plot was found to be basically symmetrical, indicating small results bias and reliable reference significance of our findings.

CONCLUSION

ERAS for perioperative patients undergoing laparoscopic surgery for GC can effectively shorten the postoperative rehabilitation cycle of patients, improve surgical safety and reduce treatment costs.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Preoperative Carbohydrate Loading on Outcomes after Cardiac Surgery: A Flawed Meta-Analysis. Comment on: "The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials". Nutrients 2020, 12, 3105

We read, with interest, the publication in Nutrients on the effects of preoperative carbohydrate loading on outcomes after cardiac surgery [...].