The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials

Challenges in Enhanced Recovery After Surgery (ERAS) research

Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking 'Why is the patient still in hospital?' is the original premise for ERAS. Outcomes improve with increased compliance with recommended elements, but overcomplication of pathways can lead to cherry picking of elements that are convenient, resulting in 'partial ERAS'. As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources.

Surgical outcomes in surgical oncology patients who participated in a family involvement program

BACKGROUND

There is a lack of evidence regarding the relationship between family involvement and outcomes in gastrointestinal oncology patients after surgery. To evaluate the effect of a family involvement program for patients undergoing oncologic gastrointestinal surgery on unplanned readmissions within 30 days after surgery.

METHODS

A multicenter patient-preference cohort study compared 2 groups: patients who participated in the family involvement program versus usual care. The program comprised involvement of family caregivers in care and training of health care professionals in family-centered care. Multivariable regression analyses were used to evaluate the effect of the FIP on the number of unplanned readmissions up to 30 days after surgery. Secondary outcomes included complications sensitive to fundamental care activities, emergency department visits, intensive care unit admissions, hospital length of stay, and the need for professional home care after discharge.

RESULTS

Of the 301 patients included, 152 chose the family involvement program, and 149 chose usual care. Postoperative readmissions occurred in 25 (16.4%) patients in the family involvement program group, and 15 (10.1%) in the usual care group (P = .11). A significant reduction of 16.2% was observed in the need for professional home care after discharge in the family involvement program group (P < .01). No significant differences were found between the 2 groups in the other secondary outcomes.

CONCLUSION

The family involvement program did not reduce the number of unplanned readmissions, but it led to a substantial reduction in-home care, which suggests an economic benefit from a societal perspective. Implementation of the family involvement program should, therefore, be considered in clinical practice.

The application of ERAS in pilonidal sinus: comparison of postoperative recovery between primary suture and Limberg flap procedure in a multicenter prospective randomized trial

Purpose

We evaluated the clinical effect of utilizing a Limberg rhomboid flap graft in conjunction with Enhanced Recovery After Surgery (ERAS) protocols for the management of pilonidal sinus in the sacrococcygeal region to demonstrate the feasibility of applying ERAS to the treatment of pilonidal sinus.

Methods

Between January 2010 and August 2018, prospective data analysis was undertaken on 109 patients who received surgical treatment for pilonidal sinus in the sacrococcygeal region at the Department of Colorectal and Anal Surgery, Jingzhou Hospital affiliated to Yangtze University, and Taizhou Affiliated Hospital of Nanjing University of Chinese Medicine. The patients were randomly separated into two groups based onoperation technique: the control group (pilonidal sinus resection with primary suture) and the observation group (pilonidal sinus resection with Limberg flap graft). Some patients in the above two groups received ERAS after surgery, which included early feeding and early ambulation, etc. Therefore, we further subdivided each group into group A (without ERAS) and group B (with ERAS) according to whether they received ERAS. Comparative analysis was conducted to assess differences in pertinent data before and after surgery across the respective groups.

Results

The length of postoperative hospitalization was shorter and wound dehiscence was more common in control group B than in control group A [(9.00 ± 1.20) vs. (11.07 ± 1.78), 26.7% (8/30) vs. 7.1% (2/28), P < 0.05]. Observation group B exhibited significantly shorter wound recovery periods and postoperative hospital stays compared to observation group A [(8.08 ± 1.20) vs. (9.16 ± 2.21), (26.23 ± 3.97) vs. (29.08 ± 4.74), P < 0.05]. The hospitalization duration and wound healing time in observation group B were notably shorter than those observed in control group B [(8.08 ± 1.20) vs. (9.00 ± 1.20), [26.23 ± 3.97 vs. (43.67 ± 7.26), P < 0.05], but the operation time was longer and scar acceptance was lower [(78.85 ± 10.16) vs. (43.30 ± 6.06), (4.00 ± 0.69) vs. (7.53 ± 0.86), P < 0.05]. The VAS score, infection rate, wound dehiscence rate, subcutaneous hematoma rate and 5-year recurrence rate in observation group B were lower than those in control group B [(5.00 ± 1.39) vs. (7.13 ± 0.78), 3.8% (1/26) vs. 23.3% (7/30), 3.8% (1/26) vs. 26.7% (8/30), 3.8% (1/26) vs. 26.7%(8/30), 7.7% (2/26) vs. 30.0% (9/30), P < 0.05], but the rate of flap ischemia or necrosis was higher [15.4% (4/26) vs. 0(0/30), P < 0.05].

Conclusion

The combination of ERAS with pilonidal sinus resection using Limberg flap graft demonstrated a reduction in infection rates, wound dehiscence, subcutaneous hematoma occurrence, and recurrence rates, along with alleviation of postoperative pain and acceleration of healing time. Comparatively, this approach offers superior advantages over pilonidal sinus resection with primary suture in the management of sacrococcygeal pilonidal sinus.

Association of the TyG index with prognosis in surgical intensive care patients: data from the MIMIC-IV

BACKGROUND

The triglyceride-glucose (TyG) index, a tool for assessing insulin resistance, is increasingly recognized for its ability to predict cardiovascular and metabolic risks. However, its relationship with trauma and surgical patient prognosis is understudied. This study investigated the correlation between the TyG index and mortality risk in surgical/trauma ICU patients to identify high-risk individuals and improve prognostic strategies.

METHODS

This study identified patients requiring trauma/surgical ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database, and divided them into tertiles based on the TyG index. The outcomes included 28-day mortality and 180-day mortality for short-term and long-term prognosis. The associations between the TyG index and clinical outcomes in patients were elucidated using Cox proportional hazards regression analysis and RCS models.

RESULTS

A total of 2103 patients were enrolled. The 28-day mortality and 180-day mortality rates reached 18% and 24%, respectively. Multivariate Cox proportional hazards analysis revealed that an elevated TyG index was significantly related to 28-day and 180-day mortality after covariates adjusting. An elevated TyG index was significantly associated with 28-day mortality (adjusted hazard ratio, 1.19; 95% confidence interval 1.04-1.37) and 180-day mortality (adjusted hazard ratio, 1.24; 95% confidence interval 1.11-1.39). RCS models revealed that a progressively increasing risk of mortality was related to an elevated TyG index. According to our subgroup analysis, an elevated TyG index is associated with increased risk of 28-day and 180-day mortality in critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases. Additionally, in nondiabetic patients, an elevated TyG index is associated with 180-day mortality.

CONCLUSION

An increasing risk of mortality was related to an elevated TyG index. In critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases, an elevated TyG index is associated with adverse short-term and long-term outcomes. Furthermore, in non-diabetic patients, an elevated TyG index is associated with adverse long-term prognosis.

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcome and Measures

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

Results

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

Conclusions and Relevance

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

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center.

METHODS

A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs).

RESULTS

A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012).

CONCLUSIONS

ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early non compliance to enhanced recovery pathway might be an alert for underlying complications following colon surgery

PURPOSE

Early non compliance to postoperative ERAS pathway has been reported in 20-30% of patients who underwent elective colon surgery. The aim of the present study is to investigate the possible relationship between early non compliance and postoperative complications.

METHODS

We reviewed a prospective database including 1391 consecutively collected patients undergoing elective colon surgery in 22 Italian hospitals between January 2017 and June 2020. Early compliance to ERAS protocol was assessed on postoperative day (POD) 2. Failure of oral feeding, urinary catheter removal, intravenous fluids stop, and adequate mobilization were indicators of non compliance. Postoperative follow-up was carried out for 30 days after hospital discharge. The association among early postoperative ERAS compliance and the occurrence of complications was assessed with uni- and multivariate analysis.

RESULTS

A total of 1089 (78.3%) patients had malignancy and minimally invasive surgery was successfully performed in 1174 (84.3%) patients. Postoperative morbidity occurred in 403 (29.0%) patients. At multivariate analysis, male gender, open surgery, and each of the four non compliance indicators on POD 2 were significantly associated to postoperative complications. Morbidity progressively increased from 16.8% in patients with full compliance to ERAS protocol to 47.2% in patients with two non compliance indicators and 69.2% in patients with all four indicators (p < 0.001).

CONCLUSIONS

Early non compliance to ERAS protocol was significantly associated with postoperative morbidity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes

BACKGROUND

Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage.

METHODS

Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes.

RESULTS

The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays.

CONCLUSION

Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

Postoperative cognitive dysfunction in elderly patients with colorectal cancer: A randomized controlled study comparing goal-directed and conventional fluid therapy

To investigate the impact of goal-directed fluid therapy (GDFT) on postoperative cognitive dysfunction (POCD) in elderly patients with colorectal cancer, we conducted a randomized controlled trial. Eighty elderly patients who underwent elective laparoscopic radical resection of colorectal cancer were randomly assigned to either the GDFT group or the conventional fluid therapy group. The primary outcome was the incidence of POCD during the initial 7 postoperative days, while secondary outcomes included inflammatory marker levels such as interleukin-6 (IL-6) and S100β protein, hemodynamics, level of lactic acid, postoperative functional recovery, and complications. Among 88 randomized patients, 80 were evaluable for the primary outcome. The incidence of POCD was significantly lower in the GDFT group (15.0%) compared to the conventional fluid therapy group (30.0%), with the highest occurrence observed on day 3 postoperatively in both groups (P < 0.05). IL-6 and S100β concentrations were consistently lower in the GDFT group than in the conventional fluid therapy group at the corresponding time points (P < 0.05). The GDFT group exhibited more stable perioperative hemodynamics and lower lactate levels (P < 0.05). Moreover, patients in the GDFT group exhibited better postoperative functional recovery indicators and a lower incidence of postoperative complications (P < 0.05). In summary, GDFT appears to reduce the incidence of early POCD, accelerate postoperative recovery, and enhance overall prognosis.

Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy

OBJECTIVE

The current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG).

EXPOSURES

Laparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not.

MAIN OUTCOMES AND MEASURES

The primary study outcome was a composite outcome called 'optimal postoperative recovery' with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics.

RESULTS

A total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21-3.34) and stepwise regression (OR 2.07, 95% CI 1.25-3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery.

CONCLUSIONS AND RELEVANCE

Patients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Length of Hospital Stay in Radical Cystectomy: A Prospective Randomized Controlled Study

Enhanced recovery after surgery (ERAS) protocols challenge the conventional and rigid methods of surgery and anesthesia and bring about novel changes that are quite drastic. The core principle of the protocol is to minimize the metabolic disturbance caused by surgical injury, facilitate the restoration of functions in a brief period, and promote the resumption of normal activity at the earliest. To compare the outcomes of ERAS and standard protocol for patients who have undergone radical cystectomy (RC) with ileal conduit urinary diversion. This prospective randomized controlled study was performed between 2015 and 2023. The 77 patients were divided into two groups ERAS (n=39) and Standard (n=38) by sequential randomization. These two groups are divided according to protocols of bowel preparation, anesthesia, and postoperative nutrition. The clinical and demographic characteristics of the patients, and the American Society of Anesthesiologists (ASA) and Eastern Cooperative Oncology Group (ECOG) scores were recorded. Perioperative findings, the degree of complications according to the Clavien-Dindo classification, and the total cost of treatment were recorded and analyzed. Length of hospital stay (18.82±9.25 day vs 27.34±15.05 day), and cost of treatment (2168,2±933$ 2879±1806$) were higher in the standard group. The rate of nausea and vomiting and the use of antiemetics were higher in the ERAS group compared to the standard group. In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.

Short-term hypercaloric carbohydrate loading increases surgical stress resilience by inducing FGF21

Dietary restriction promotes resistance to surgical stress in multiple organisms. Counterintuitively, current medical protocols recommend short-term carbohydrate-rich drinks (carbohydrate loading) prior to surgery, part of a multimodal perioperative care pathway designed to enhance surgical recovery. Despite widespread clinical use, preclinical and mechanistic studies on carbohydrate loading in surgical contexts are lacking. Here we demonstrate in ad libitum-fed mice that liquid carbohydrate loading for one week drives reductions in solid food intake, while nearly doubling total caloric intake. Similarly, in humans, simple carbohydrate intake is inversely correlated with dietary protein intake. Carbohydrate loading-induced protein dilution increases expression of hepatic fibroblast growth factor 21 (FGF21) independent of caloric intake, resulting in protection in two models of surgical stress: renal and hepatic ischemia-reperfusion injury. The protection is consistent across male, female, and aged mice. In vivo, amino acid add-back or genetic FGF21 deletion blocks carbohydrate loading-mediated protection from ischemia-reperfusion injury. Finally, carbohydrate loading induction of FGF21 is associated with the induction of the canonical integrated stress response (ATF3/4, NF-kB), and oxidative metabolism (PPARγ). Together, these data support carbohydrate loading drinks prior to surgery and reveal an essential role of protein dilution via FGF21.

RESIDUAL GASTRIC VOLUME IN MORBIDLY OBESE DIABETICS AFTER AN OVERNIGHT FASTING OR 3 HOURS OF A CARBOHYDRATE-ENRICHED SUPPLEMENT: A RANDOMIZED CROSSOVER PILOT STUDY

BACKGROUND

To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients.

AIMS

The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting.

METHODS

This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05.

RESULTS

The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82).

CONCLUSIONS

Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.

Anterior Quadratus Lumborum Block at Lateral Supra-Arcuate Ligament vs Lateral Quadratus Lumborum Block for Postoperative Analgesia after Laparoscopic Colorectal Surgery: A Randomized Controlled Trial

BACKGROUND

Quadratus lumborum block (QLB) has been found to be advantageous for laparoscopic colorectal surgery. This study hypothesized that preoperative anterior QLB at lateral supra-arcuate ligament (QLB-LSAL) would decrease postoperative opioid usage and offer improved analgesia within the context of multimodal analgesia compared with lateral QLB (LQLB) for laparoscopic colorectal surgery.

STUDY DESIGN

In this randomized controlled trial, 82 American Society of Anesthesiologists physical status I to III class colorectal cancer patients undergoing laparoscopic radical resection were enrolled and randomly assigned to receive either LQLB or QLB-LSAL (0.375% ropivacaine 0.3 mL/kg bilaterally for each group). The primary outcomes were the total intravenous morphine equivalent consumption at 24 hours postoperatively.

RESULTS

Intravenous morphine equivalent consumption at 24 hours postoperatively was significantly reduced in the QLB-LSAL group compared with that in the LQLB group with per-protocol analysis (29.2 ± 5.8 vs 40.5 ± 9.6 mg, p < 0.001) and intention-to-treat analysis (29.6 ± 6.1 vs 40.8 ± 9.5 mg, p < 0.001). Time to first patient-controlled analgesia request was notably longer in the QLB-LSAL group than that in the LQLB group (10.4 ± 3.9 vs 3.7 ± 1.5 hours, p < 0.001).

CONCLUSIONS

Preoperative bilateral ultrasound-guided QLB-LSAL reduces morphine usage and extends the duration until the first patient-controlled analgesia demand within the framework of multimodal analgesia when compared with LQLB after laparoscopic colorectal surgery.

Enhanced recovery after surgery for liver transplantation: a review of recent literature

PURPOSE OF REVIEW

This review was created to highlight important articles from the past year related to the evolving field of enhanced recovery after surgery (ERAS) in liver transplantation that are relevant to the transplant anesthesiologist.

RECENT FINDINGS

The International Liver Transplantation Society (ILTS) recently completed a landmark project, the ERAS4OLT.org project, which culminated in 80 recommendations for ERAS in liver transplantation. These recommendations encompass management for deceased donor recipients, living donor recipients and living donors. This review highlights selected articles relevant to the perioperative management of deceased donor liver transplant recipients.

SUMMARY

Though, there are now published internationally agreed upon recommendations for ERAS topics specific to liver transplantation, there is an obvious need for further investigation into this area to provide high quality evidence to support these recommendations. It is reasonable to utilize these recommendations in ERAS protocols for individual institutions; however, more evidence is needed in several areas to confirm the effects of these protocols on short-term outcomes.

Effectiveness of acupuncture for postoperative gastrointestinal recovery in patients undergoing thoracoscopic surgery: a prospective randomized controlled study

BACKGROUND

Postoperative gastrointestinal dysfunction (PGD) is one of the most common complications among patients who have undergone thoracic surgery. Acupuncture has long been used in traditional Chinese medicine to treat gastrointestinal diseases and has shown benefit as an alternative therapy for the management of digestive ailments. This study aimed to explore the therapeutic effectiveness of acupuncture as a means to aid postoperative recovery of gastrointestinal function in patients undergoing thoracoscopic surgery.

METHODS

In total, 112 patients aged 18-70 years undergoing thoracoscopic surgery between 15 June 2022 and 30 August 2022 were randomized into two groups. Patients in the acupuncture group (AG) first received acupuncture treatment 4 h after surgery, and treatment was repeated at 24 and 48 h. Patients in the control group (CG) did not receive any acupuncture treatment. Both groups received the same anesthetic protocol. Ultrasound-guided thoracic paravertebral block (TPVB) was performed in the paravertebral spaces between T4 and T5 with administration of 20 mL of 0.33% ropivacaine. All patients received patient-controlled intravenous analgesia (PCIA) after surgery.

RESULTS

Median time to first flatus [interquartile range] in the AG was significantly less than in the CG (23.25 [18.13, 29.75] vs 30.75 [24.13, 45.38] h, p < 0.001). Time to first fluid intake after surgery was significantly less in the AG, as compared with the CG (4 [3, 7] vs 6.5 [4.13, 10.75] h, p = 0.003). Static pain, measured by visual analog scale (VAS) score, was significantly different on the third day after surgery (p = 0.018). Dynamic pain VAS scores were lower in the AG versus CG on the first three postoperative days (p = 0.014, 0.003 and 0.041, respectively).

CONCLUSION

Addition of acupuncture appeared to improve recovery of postoperative gastrointestinal function and alleviate posteoperative pain in patients undergoing thoracoscopic surgery. Acupuncture may represent a feasible strategy for the prevention of PGD occurrence.

TRIAL REGISTRATION NUMBER

ChiCTR2200060888 (Chinese Clinical Trial Registry).

Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital

PURPOSE

Enhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period.

METHODS

This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire.

RESULTS

A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001).

CONCLUSION

An ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.

Impact of Enhanced Recovery after Surgery® Protocol Compliance on Length of Stay, Bowel Recovery and Complications after Radical Cystectomy

BACKGROUND

Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC).

METHODS

Data from consecutive patients undergoing RC for BC within an ERAS® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS® compliance was extracted from the ERAS® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI.

RESULTS

After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS® protocol and age > 75 years were significant independent predictors of POI.

CONCLUSIONS

Our study provides further evidence to support the beneficial effect of the ERAS® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Transforming Bariatric Surgery Outcomes: The Pivotal Role of Enhanced Recovery After Surgery (ERAS) Protocols in Patient-Centered Care

Bariatric surgery is a critical strategy in managing morbid obesity. Enhanced recovery after surgery (ERAS) protocols have revolutionized perioperative care in this field. This systematic review aims to synthesize current evidence on the impact of ERAS protocols on patient-centered outcomes in bariatric surgery. A comprehensive search across multiple databases was conducted, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies involving adult patients undergoing bariatric surgery and focusing on the implementation and outcomes of ERAS protocols were included. Data extraction and analysis emphasized patient recovery, well-being, and satisfaction. Eleven studies met the inclusion criteria. The review revealed that ERAS protocols are associated with reduced postoperative recovery times, decreased hospital stays, and enhanced patient satisfaction. Notably, ERAS protocols effectively reduced complications and optimized resource utilization in bariatric surgery. Comparative insights from non-bariatric surgeries highlighted the versatility and adaptability of ERAS protocols across different surgical disciplines. ERAS protocols significantly improve patient-centered outcomes in bariatric surgery. Their adoption facilitates a patient-focused approach, accelerating recovery and enhancing overall patient well-being. The findings advocate for the broader implementation of ERAS protocols in surgical care, emphasizing the need for continuous refinement to meet evolving healthcare demands. This review supports the paradigm shift toward integrating ERAS protocols in bariatric surgery and potentially other surgical fields.

Impact of enhanced recovery after surgery (ERAS) guidelines implementation in cesarean delivery: A systematic review and meta-analysis

BACKGROUND

Cesarean delivery rate is increasing, with no prediction of this rate to drop. Implementation of Early Recovery After Surgery (ERAS) program adapted to this high prevalent obstetrical surgical procedure proposes better peri-operative care achievement with improved maternal medical care, namely reduced morbidity, faster return to normal daily activities and improved impact on quality of life. Our aim was to analyze the outcomes of ERAS guidelines implementation in cesarean sections (CS).

MATERIAL AND METHODS

A systematic review was performed across 3 databases (MEDLINE (Pubmed), Scopus and Web of Science), with no time or language filters, for articles comparing outcomes on pregnant women who delivered via CS with ERAS guidelines implementation versus the traditional approach without ERAS implementation. Outcomes established: primary - hospital length of stay; secondary - opioid consumption, readmission rates and maternal complications (overall, surgical site infection and emetic morbidity). Statistical analyses were conducted using Review Manager 5.4 and its results were expressed as mean difference, standardized mean difference and odds ratio, with 95% of confidence intervals. This systematic review was reported according to the PRISMA statement.

RESULTS

This systematic review included 16 studies (3 randomized controlled trials (RCT), 4 prospective cohorts and 9 retrospective cohorts), with a pool analysis of 19,001 women (9752 with the traditional approach and 9249 following ERAS guidelines). Our results showed a significative decrease in length of hospital stay (MD: -13.78 h; CI 95 % -19.28 to -8.28; p < 0.00001) and opioid consumption (SMD: -0.91; CI 95 % -1.51 to -0.32; p = 0.003), with similar readmission rates (OR: 0.85; CI 95 % 0.50 to 1.44; p = 0.53) and maternal complications, namely: overall (OR: 0.87; CI 95 % 0.56 to 1.35; p = 0.53); surgical site infection (OR: 1.13; CI 95 % 0.72 to 1.77; p = 0.60) and emetic morbidity (OR: 0.78; CI 95 % 0.31 to 1.96; p = 0.60).

CONCLUSIONS

ERAS guidelines applied at CS management are associated with decreased length of stay and opioid consumption, without negatively impact on readmission rates and overall maternal complications, including surgical site infection and emetic morbidity. The reduced number of RCT studies and the heterogeneity of the studies (heterogeneous inter-study protocols) constitutes the major limitation of the evidence found. Still, these findings may be a foremost help to confirm the beneficial impact of an ERAS approach during peri-cesarean management.

Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward

BACKGROUND

Enhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions.

METHODS

We collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance.

RESULTS

Enhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay.

CONCLUSION

This study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.

Evidence-based Perioperative Practice Utilization among Various Racial Populations-A Retrospective Cohort Trending Analysis of Lower Extremity Total Joint Arthroplasty Patients

BACKGROUND

Various studies have demonstrated racial disparities in perioperative care and outcomes. The authors hypothesize that among lower extremity total joint arthroplasty patients, evidence-based perioperative practice utilization increased over time among all racial groups, and that standardized evidence-based perioperative practice care protocols resulted in reduction of racial disparities and improved outcomes.

METHODS

The study analyzed 3,356,805 lower extremity total joint arthroplasty patients from the Premier Healthcare database (Premier Healthcare Solutions, Inc., USA). The exposure of interest was race (White, Black, Asian, other). Outcomes were evidence-based perioperative practice adherence (eight individual care components; more than 80% of these implemented was defined as "high evidence-based perioperative practice"), any major complication (including acute renal failure, delirium, myocardial infarction, pulmonary embolism, respiratory failure, stroke, or in-hospital mortality), in-hospital mortality, and prolonged length of stay.

RESULTS

Evidence-based perioperative practice adherence rate has increased over time and was associated with reduced complications across all racial groups. However, utilization among Black patients was below that for White patients between 2006 and 2021 (odds ratio, 0.94 [95% CI, 0.93 to 0.95]; 45.50% vs. 47.90% on average). Independent of whether evidence-based perioperative practice components were applied, Black patients exhibited higher odds of major complications (1.61 [95% CI, 1.55 to 1.67] with high evidence-based perioperative practice; 1.43 [95% CI, 1.39 to 1.48] without high evidence-based perioperative practice), mortality (1.70 [95% CI, 1.29 to 2.25] with high evidence-based perioperative practice; 1.29 [95% CI, 1.10 to 1.51] without high evidence-based perioperative practice), and prolonged length of stay (1.45 [95% CI, 1.42 to 1.48] with high evidence-based perioperative practice; 1.38 [95% CI, 1.37 to 1.40] without high evidence-based perioperative practice) compared to White patients.

CONCLUSIONS

Evidence-based perioperative practice utilization in lower extremity joint arthroplasty has been increasing during the last decade. However, racial disparities still exist with Black patients consistently having lower odds of evidence-based perioperative practice adherence. Black patients (compared to the White patients) exhibited higher odds of composite major complications, mortality, and prolonged length of stay, independent of evidence-based perioperative practice use, suggesting that evidence-based perioperative practice did not impact racial disparities regarding particularly the Black patients in this surgical cohort.

EDITOR’S PERSPECTIVE

Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization.

METHODS

This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups.

RESULTS

Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011).

CONCLUSIONS

Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.

Enhanced Recovery After Surgery (ERAS) Approach: A Medical Complex Experience

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach aimed at reducing organ failure and mitigating stress reactions in surgery patients. This investigation sought to assess available data concerning the benefits of ERAS protocols in improving patient outcomes for individuals undergoing significant colorectal surgery.

METHODS

The study involved 65 patients who underwent colectomy and lower anterior resection for rectal cancers. Patients were divided into three groups: Group 1 comprised 22 patients enrolled retrospectively who received the traditional protocol; Group 2 consisted of 20 patients enrolled prospectively who received the ERAS protocol; and Group 3 included 23 patients enrolled retrospectively who received the ERAS protocol. Each patient underwent a comprehensive history, physical examination, laboratory testing, computed tomography, MRI, and chest radiography.

RESULTS

Hospital stay durations were significantly shorter in both ERAS groups during the first and second cycles compared to the non-ERAS group (P<0.001, <0.001), with no significant difference between ERAS groups in either cycle. Delayed intestinal motility was significantly more pronounced in the non-ERAS group compared to ERAS groups in both cycles (P=0.005), with only five (22.7%) cases reported in the non-ERAS group.

CONCLUSION

ERAS implementation in the perioperative management of colorectal surgery patients is associated with improved outcomes and shorter recovery times. Implementation of ERAS in hospitals is feasible and beneficial.

Perioperative Lidocaine Infusion Reduces Opioid Use in Enhanced Recovery After Surgery Patients Undergoing Laparoscopic Colectomy

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have become a mainstay of modern surgical care, and efforts to decrease postoperative opioid consumption have been increasingly employed. A previous study from our institution demonstrated that ERAS protocols decreased opioid use in the first 48 hours after surgery by 61%. In the present study, a lidocaine infusion was added for postoperative pain control. The aim was to analyze the differences in opioid requirements with and without this infusion in the first 48 hours after laparoscopic colectomy in ERAS patients.

METHODS

Retrospective review of patients was conducted at an academically affiliated tertiary care hospital. The population included patients undergoing elective laparoscopic colon surgery enrolled in the ERAS program with the implementation of a lidocaine drip from June 2019 to October 2019, and compared to a previous patient cohort of ERAS patients evaluated without the lidocaine drip from September 2015 to May 2018.

RESULTS

The primary endpoint was postoperative opioid use in the first 48 hours based on IV morphine milligram equivalents (MME). Secondary measures included type of surgery, age, BMI, prior abdominal surgery, and prior opioid use. Median MMEs were 6.0 in the lidocaine infusion group and 12.5 in the group without lidocaine, representing a 52% reduction (p < 0.001).

DISCUSSION

This study demonstrates a significant reduction in post-op opioid use in ERAS patients who receive a lidocaine infusion after laparoscopic colectomy. Further studies should focus on measures to limit the treatment side effects in order to maximize the opioid-sparing benefits of this intervention.

Global Trends in Research of Perioperative Analgesia Over Past 10 Years: A Bibliometric Analysis

Background

The postoperative acute pain caused by surgery has been a major problem plaguing anesthesiologists, and even some acute pain progresses to chronic pain syndrome, terribly reducing the quality of life of patients. To this end, increasing attention has been paid to the management of perioperative analgesia. At present, with the increase of research on perioperative analgesia, the understanding and solution of this clinical problem have been further developed. Bibliometrics can estimate research hot-spots and trends of related fields in a certain period of time. However, a systematic bibliometric analysis has not been conducted to explore current research hotspots and future development trends, which is thus the purpose of this study.

Methods

Articles and reviews published from 2012 to 2021 were retrieved from the Web of Science Core Collection (WoSCC) database, and the bibliometric analysis of the keywords and references of articles was performed using VOSviewer1.6.18. Besides, the number of articles related to perioperative analgesia in term of countries, affiliations, authors, and journals were analyzed.

Results

Finally, 3157 articles meeting the screening requirements were retrieved, and it was hereby found that the research on perioperative analgesia had received more attention and interest in the past 10 years, with the United States making more contributions, where there were eight of the top ten affiliations by the number of publications. Kaye AD was the most active researcher in this field. Most related articles were published in Anesthesia and Analgesia, accounting for 2.76% of all literature. Enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention were the main trends and hotspots.

Conclusion

Perioperative analgesia has attracted considerable academic interest. In the past decade, the effects of enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention on perioperative analgesia have become the research hotspots, which are also likely to be the focus of future study.

Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS)

Background

Enhanced recovery after surgery (ERAS) protocols have largely been incorporated into practice in high-income settings due to proven improvement in perioperative outcomes. We aimed to review the implementation of ERAS protocols and other perioperative optimisation strategies in low- and middle-income countries (LMICs) and their impact on length of hospital stay (LOS).

Methods

We searched MEDLINE, PubMed, Global Health (CABI), WHO Global Index Medicus, Index Medicus, and Latin American and Caribbean Health Sciences Literature (LILACS) for studies incorporating ERAS or other prehabilitation approaches in LMICs. We conducted a pooled analysis of LOS using a random-effects model to evaluate the impact of such programs. This systematic review was pre-registered on PROSPERO.

Results

We screened 1205 studies and included 70 for a full-text review; six were eligible for inclusion and five for quantitative analysis, two of which were randomised controlled trials. ERAS was compared to routine practice in all included studies, while none implemented prehabilitation or other preoperative optimisation strategies. Pooled analysis of 290 patients showed reduced LOS in the ERAS group with a standardised mean difference of -2.18 (95% confidence interval (CI) = -4.13, -.0.05, P < 0.01). The prediction interval was wide (95% CI = -7.85, 3.48) with substantial heterogeneity (I2 = 94%).

Conclusions

Perioperative optimisation is feasible in LMICs and appears to reduce LOS, despite high levels of between-study heterogeneity. There is a need for high-quality data on perioperative practice in LMICs and supplementary qualitative analysis to further understand barriers to perioperative optimisation implementation.

Registration

PROSPERO: CRD42021279053.

A Survey on Enhanced Recovery After Surgery (ERAS) Elements in Cleft Palate Repair

This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons.

Craniofacial surgeons were provided with electronic surveys.

Electronic survey; Institutional tertiary surgeons.

102 cleft palate surgeons surveyed and 31 completed the survey (30.4%).

None.

Respondents rated their knowledge, use, and willingness to implement perioperative interventions modeled after adult ERAS protocols.

Majority (67.7%) rated they were knowledgeable about ERAS. However, 61.3% "never use" a standardized protocol for cleft palate surgery. Only 3 ERAS elements are currently implemented by a majority of cleft surgeons: avoiding prolonged perioperative fasting (67.7%), using hypothermia prevention measures (74.2%), and minimizing use of opioids (62.5%). A large majority of respondents noted they never administer bolus (71.0%) or infusion (80.6%) dosing of tranexamic acid; most of these surgeons also indicated that administering tranexamic acid "would not be a valuable addition" (67.7% and 71.0%, respectively). Short-acting sedatives are used by 12.9% and by 16.1% of surgeons in all patients during extubation and postoperative recovery, respectively. By contrast, 22.6% never use such agents during extubation and 48.4% never use it during postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repair.

Many respondents report using interventions compatible with an ERAS approach and the majority are willing to implement an ERAS protocol for cleft palate repair.

Perioperative nutritional assessment and support in visceral surgery

Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.

Advantages of enhanced recovery after surgery program in robot-assisted radical cystectomy

Radical cystectomy is a gold-standard treatment for muscle-invasive bladder cancer. We recently introduced robot-assisted radical cystectomy (RARC) with perioperative enhanced recovery after surgery (ERAS). The medical records of patients with bladder cancer who underwent open radical cystectomy (ORC) or RARC/ERAS at NTT Medical Center Tokyo were retrospectively reviewed to compare the surgical outcomes, hospital stay, and medical costs between groups. Multidisciplinary full ERAS items were provided for the RARC/ERAS group. The median estimated blood losses in the ORC and RARC/ERAS groups were 650 and 100 mL, and the median operative times were 312 and 445 min, respectively. In addition, the median times to liquid food intake in these groups were 6 and 0 days, the median times to first flatus and first defecation were 2 and 1 day, and 3 and 1.5 days, respectively. The rates of postoperative ileus in the ORC and RARC/ERAS groups were 27.5% and 4.5%, and the median postoperative hospital stays was 26.5 and 12 days, respectively. Medical costs excluding surgery were significantly lower in the RARC/ERAS group. In conclusion, RARC/ERAS represents a safe treatment option for muscle-invasive bladder cancer with decreased perioperative complications and lower medical costs.

Role of the protein kinase A signaling pathway and identification of mediators in the cardioprotective effects of enteral lactoferrin for ischemia-reperfusion injury in an isolated rat heart model

OBJECTIVE

Lactoferrin is an iron-binding glycoprotein. Enteral lactoferrin attenuates myocardial ischemia-reperfusion (IR) injury, but the underlying mechanism remains unknown. The aim of this study was to investigate protein kinase A (PKA) signaling pathway activation and levels of serum glucagonlike peptide-1 (GLP-1), secreted by intestinal endocrine L cells, and adiponectin, secreted by adipose tissue, after enteral lactoferrin administration.

METHODS

Hearts (N = 32) were excised from Wistar rats and perfused using a Langendorff system. To assess the role of the PKA pathway in the cardioprotective effects of lactoferrin, an inhibitor of PKA (H89) was applied before no-flow ischemia. Rats were randomly divided into four groups: control, lactoferrin (LF), control+H89, and LF+H89. The control and control+H89 groups were administered normal saline by gavage, and the LF and L +H89 groups were administered bovine lactoferrin (1000 mg/kg) by gavage 15 min before intraperitoneal pentobarbital injection. Muscle sampling was performed at the end of reperfusion. When rats were sacrificed, blood was sampled to measure hormone levels. The primary outcome was maximum left ventricular pressure derivative (LV dP/dt max) 15 min after reperfusion.

RESULTS

LV dP/dt max at 10 and 15 min after reperfusion was significantly higher in the LF group than in the control group (P < 0.05), and the effect was diminished by H89. The PKA pathway was significantly activated in the LF group. Enteral lactoferrin increased serum GLP-1 but not serum adiponectin levels.

CONCLUSIONS

Enteral lactoferrin induces cardioprotective effects against myocardial IR injury via the PKA signaling pathway and increases serum GLP-1 levels.

Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery

OBJECTIVE

To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use.

METHODS

This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests.

RESULTS

A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002).

CONCLUSION

An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.

Day surgery unit robotics thoracic surgery: feasibility and management

BACKGROUND

Day surgery has been widely carried out in medical developed countries such as Europe and the United States with high efficiency, safety and economy. The development of thoracic day surgery started late, and currently only a few top three hospitals carry thoracic day surgery. In recent years, with the continuous in-depth application of the concept of accelerated rehabilitation surgery (ERAS) in the field of surgery, thoracic surgery ERAS has also entered clinical practice with remarkable results. At present, the application of day surgery in the field of thoracic surgery is still in its infancy, and the application of robot-assisted thoracic surgery in thoracic surgery has brought new opportunities for the popularization of day surgery in thoracic surgery.

METHODS

We retrospectively reviewed 86 patients underwent thoracic day surgery under the application of robot-assisted surgery system and through systematic randomization method choose 86 patients underwent conventional thoracic surgery under the application of robot-assisted surgery system at our Institute between 2020 and 2022. We analyzed the clinical and pathological features between the two groups.

RESULTS

The clinical feature of location of the nodules, the size of nodules, pN, histology and postoperative complications were homogenous between the two groups. The average age was significantly higher in the conventional mode group, the ratio of male patients and the patients with history of smoking were significantly lower in day-surgery mode group. The major surgical method in conventional mode group was lobectomy resection (48.8%). While the segmental resection was the major surgical in day surgery mode group. The hospital stay and the time of drain was significant longer in conventional mode group. And the total medical cost in conventional was more than day-surgery mode group. While the histology and postoperative complications were homogenous between the two groups.

CONCLUSION

Before this, day surgery and robotics assistant surgery in thoracic surgery had been proved feasibility and safety. However, there was no report of day surgery unit robotics assistant thoracic surgery. Our clinical practice demonstrated that the method of day surgery unit robotics thoracic surgery is feasibility and safety enough.

Enhanced Recovery After Surgery (ERAS) Protocols for Improving Outcomes for Patients Undergoing Major Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have gained recognition as a perioperative care approach for patients undergoing major colorectal surgery. This systematic review aims to evaluate the effects of ERAS protocols on outcomes in this patient population. A systematic search was conducted in PubMed, Cochrane Library, and Embase databases for studies published between January 2010 and September 2021. Inclusion criteria encompassed studies assessing the impact of ERAS protocols on patients undergoing major colorectal surgery. Data were extracted, and a qualitative synthesis of the included studies was performed. A total of 18 studies met the inclusion criteria. The implementation of ERAS protocols was associated with several positive outcomes. Compared to traditional care, ERAS protocols significantly reduced the length of hospital stay (mean difference [MD]: -1.64 days, 95% confidence interval [CI]: -2.21 to -1.08, p<0.00001), postoperative complications (odds ratio [OR]: 0.57, 95% CI: 0.46 to 0.71, p<0.00001), and readmission rates (OR: 0.57, 95% CI: 0.38 to 0.85, p=0.006). ERAS protocols also led to a shorter time to return of bowel function (MD: -0.74 days, 95% CI: -1.03 to -0.45, p<0.00001), time to first mobilization (MD: -0.55 days, 95% CI: -0.82 to -0.28, p<0.0001), and time to first oral intake (MD: -0.62 days, 95% CI: -0.95 to -0.28, p=0.0003). Additionally, patients reported higher satisfaction levels with the implementation of ERAS protocols (MD: 1.02, 95% CI: 0.19 to 1.86, p=0.02). This systematic review demonstrates that the implementation of ERAS protocols in major colorectal surgery is associated with improved outcomes. ERAS protocols lead to reduced hospital stays, lower postoperative complications, and decreased readmission rates. Furthermore, they facilitate faster recovery of bowel function, mobilization, and oral intake. Patients also express higher satisfaction levels with ERAS implementation. Healthcare providers should consider adopting ERAS protocols to optimize perioperative care in patients undergoing major colorectal surgery.

Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction

INTRODUCTION

Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction.

METHODS

In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis.

RESULTS

The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol.

CONCLUSION

The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.

Remote Home Monitoring of Continuous Vital Sign Measurements by Wearables in Patients Discharged After Colorectal Surgery: Observational Feasibility Study

BACKGROUND

Hospital stays after colorectal surgery are increasingly being reduced by enhanced recovery and early discharge protocols. As a result, postoperative complications may frequently manifest after discharge in the home setting, potentially leading to emergency room presentations and readmissions. Virtual care interventions after hospital discharge may capture clinical deterioration at an early stage and hold promise for the prevention of readmissions and overall better outcomes. Recent technological advances have enabled continuous vital sign monitoring by wearable wireless sensor devices. However, the potential of these devices for virtual care interventions for patients discharged after colorectal surgery is currently unknown.

OBJECTIVE

We aimed to determine the feasibility of a virtual care intervention consisting of continuous vital sign monitoring with wearable wireless sensors and teleconsultations for patients discharged after colorectal surgery.

METHODS

In a single-center observational cohort study, patients were monitored at home for 5 consecutive days after discharge. Daily vital sign trend assessments and telephone consultations were performed by a remote patient-monitoring department. Intervention performance was evaluated by analyzing vital sign trend assessments and telephone consultation reports. Outcomes were categorized as "no concern," "slight concern," or "serious concern." Serious concern prompted contact with the surgeon on call. In addition, the quality of the vital sign data was determined, and the patient experience was evaluated.

RESULTS

Among 21 patients who participated in this study, 104 of 105 (99%) measurements of vital sign trends were successful. Of these 104 vital sign trend assessments, 68% (n=71) did not raise any concern, 16% (n=17) were unable to be assessed because of data loss, and none led to contacting the surgeon. Of 62 of 63 (98%) successfully performed telephone consultations, 53 (86%) did not raise any concerns and only 1 resulted in contacting the surgeon. A 68% agreement was found between vital sign trend assessments and telephone consultations. Overall completeness of the 2347 hours of vital sign trend data was 46.3% (range 5%-100%). Patient satisfaction score was 8 (IQR 7-9) of 10.

CONCLUSIONS

A home monitoring intervention of patients discharged after colorectal surgery was found to be feasible, given its high performance and high patient acceptability. However, the intervention design needs further optimization before the true value of remote monitoring for early discharge protocols, prevention of readmissions, and overall patient outcomes can be adequately determined.

Does stoma modify compliance with enhanced recovery after surgery programs? Results of a cohort study

PURPOSE

Few studies have focused on enhanced recovery programs (ERPs) in patients who have received a stoma after colorectal surgery. The objective of the study was to compare ERP compliant patients who have not received a stoma, those who received a colostomy, and those who received an ileostomy.

METHODS

This study used data that had been prospectively collected as part of the ERP audit performed through the Groupe francophone de Réhabilitation Améliorée après Chirurgie [Francophone Group for Enhanced Recovery after Surgery] over a 4-year period. All patients who had undergone colorectal surgery were included and separated into three groups (no stoma, ileostomy, and colostomy). The primary outcome was ERP compliance, calculated through the use of 16 tracer items.

RESULTS

Of the 422 recruited patients, 317 had not received a stoma (75.12%), 59 had an ileostomy (13.98%), and 46 had a colostomy (10.90%). ERP compliance was 73% in the non-stoma group, 66.6% in the ileostomy group, and 66% in the colostomy group (p < 0.001). Multivariate analysis showed that patients from the ileostomy group had a higher risk of bowel preparation [OR = 9.1; 95% CI = 1.16-71.65] and of maintaining their urinary catheter [OR = 0.3; 95% CI = 0.14-0.81] than the group which did not receive a stoma. Patients from the colostomy group required significantly more drainage than those in the non-stoma group (OR = 4.3; 95% CI = 1.33-14.02).

CONCLUSION

ERP is feasible in colorectal surgery in the context of stomas, but in case of ileostomy protecting a rectal surgery, the audit system must be adapted to the protocols in use in the departments.

Truth of Colorectal Enhanced Recovery Programs: Process Measure Compliance in 151 Hospitals

BACKGROUND

Commonly cited studies have reported substantial improvements (defined as >20%) in process measure compliance after implementation of colorectal enhanced recovery programs (ERPs). However, hospitals have anecdotally reported difficulties in achieving similar improvement gains. This study evaluates improvement uniformity among 151 hospitals exposed to an 18-month implementation protocol for 6 colorectal ERP process measures (oral antibiotics, mechanical bowel preparation, multimodal pain control, early mobilization, early liquid intake, and early solid intake).

STUDY DESIGN

One hundred fifty-one hospitals implemented a colorectal ERP with pathway, educational and supporting materials, and data capture protocols; 906 opportunities existed for process compliance improvement across the cohort (151 hospitals × 6 process measures). However, 240 opportunities were excluded due to high starting compliance rates (ie compliance >80%) and 3 opportunities were excluded because compliance rates were recorded for fewer than 2 cases. Thus, 663 opportunities for improvement across 151 hospitals were studied.

RESULTS

Of 663 opportunities, minimal improvement (0% to 20% increase in compliance) occurred in 52% of opportunities, substantial improvement (>20% increase in compliance) in 20%, and worsening compliance occurred in 28%. Of the 6 processes, multimodal pain control and use of oral antibiotics improved the most.

CONCLUSIONS

Contrary to published ERP literature, the majority of study hospitals had difficulty improving process compliance with 80% of the opportunities not achieving substantial improvement. This discordance between ERP implementation success rates reported in the literature and what is observed in a large sample could reflect differences in hospitals' culture or characteristics, or a publication bias. Attention needs to be directed toward improving ERP adoption across the spectrum of hospital types.

Incremental Cost-effectiveness Analysis on Length of Stay of an Enhanced Recovery After Spine Surgery Program: A Single-center, Retrospective Cohort Study

BACKGROUND

Enhanced recovery after spine surgery (ERAS) is increasingly utilized to improve postoperative outcomes and reduce cost. There are limited data on the monetary benefits of ERAS when incorporating the costs of developing, operationalizing, and maintaining ERAS programs. The objective of this study was to calculate the incremental cost-effectiveness of a spine surgery ERAS program, modeling hospital and operational cost and length of stay (LOS).

METHODS

The study included adult patients undergoing spine surgery before and after implementation of an ERAS program. Variables included individual patient-level and ERAS personnel costs, with LOS as the outcome utility of interest. Propensity score matching was used to create a quasi-experimental design to equate the standard care and ERAS groups.

RESULTS

Four hundred and nine patients were included in the unmatched group, with 54 patients each in the standard care and ERAS groups after matching. In the matched cohort, the only imbalance in predictors (standard mean difference [SMD] >0.2) were race (SMD, 0.21), American Society of Anesthesiologist (ASA) physical status (SMD, 0.32), fluid balance in the operating room (SMD, 0.21), median (interquartile range) LOS (standard care, 2.0 [1.0, 3.75] days vs. ERAS, 4.0 [3.0, 5.0]; SMD, 0.81) and mean (±SD) total cost (standard care, $19,291.57±13,572.24 vs. ERAS, $24,363.45±26,352.45; SMD, 0.24). In the incremental cost effectiveness analysis, standard care was the dominant strategy in both 1-way and 2-way sensitivity analysis.

CONCLUSIONS

We report a real-world, cost-effectiveness analysis following implementation of an ERAS program for spine surgery at a quaternary medical center. Our study demonstrated that considering LOS as the sole determinant, standard care is the dominant cost-effective strategy compared with the ERAS protocol.

Microbiome Contributions to Health

The human microbiome is vast and is present in spaces previously thought to be sterile such as the lungs. A healthy microbiome is diverse and functions in an adaptive way to support local as well as organism health and function. Furthermore, a normal microbiome is essential for normal immune system development rendering the array of microbes that live in and on the human body key components of homeostasis. A wide array of clinical conditions and interventions including anesthesia, analgesia, and surgical intervention may derange the human microbiome in a maladaptive fashion with bacterial responses spanning decreased diversity to transformation to a pathogenic phenotype. Herein, we explore the normal microbiome of the skin, gastrointestinal tract, and the lungs as prototype sites to describe the influence of the microbiomes in each of those locations on health, and how care may derange those relations.

Everyday challenges following hospital discharge. A multi-method study identifying and describing areas of concern for patients during the first month after colorectal cancer surgery

AIM

Identify and describe areas of concern focusing on day-to-day variations during the first month after surgery for patients recovering from colorectal cancer surgery.

DESIGN

A multi-method design was applied using diaries and interviews.

METHOD

Data was collected using semi-structured diaries kept 1 month after surgery by seven patients recovering from colorectal cancer surgery. Also, face-to-face interviews were conducted 1 month after surgery. Data from the diaries constituted a framework for the following directed content analysis of interviews.

FINDINGS

Low levels of pain were experienced but caused reduced mobility and tiredness. Practical matters in daily living were restricted, while social life could be hampered by a frequent need to defecate. Appetite and consequently the ability to eat and drink was the most prominent concern, due to changes in taste and ability to tolerate food. Worries were mainly related to changes in bowel movements. No Patient or Public Contribution.