The efficacy and safety of enhanced recovery after surgery (ERAS) program in laparoscopic digestive system surgery: A meta-analysis of randomized controlled trials

The efficacy and safety of enhanced recovery after surgery (ERAS) Program in laparoscopic distal gastrectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although ERAS Program had some advantages in laparoscopic distal gastrectomy (LDG), its efficacy and safety remained unclear. We conducted a systematic review and meta-analysis to assess the efficacy and safety of the ERAS group and the traditional care (TC) group in LDG.

METHODS

Multiple databases were retrieved from 1 January 2000 to 30 April 2023. The risk ratio (RR), standardized mean difference (SMD) and their 95% confidence interval (CI) were used to estimate the results.

RESULTS

Our meta-analysis contained 17 randomized controlled trials (RCTs) studies, which comprised 1468 patients. Regarding efficacy, the ERAS group had significantly shorter postoperative time to first flatus (SMD = -1.29 [95% CI: -1.68, -0.90]), shorter time to first defecation (SMD = -1.26 [95% CI: -1.90, -0.61]), shorter hospital stays (SMD = -0.99 [95% CI: -1.34, -0.63]), and lower hospitalization costs (SMD = -1.17 [95% CI: -1.86, -0.48]) compared to the TC group. Furthermore, in the ERAS group, C-reactive protein levels were lower on postoperative days 1, 3 or 4, and 7; albumin levels were higher on postoperative days 3 or 4 and 7; and interleukin-6 levels were lower on postoperative days 1 and 3. Regarding safety, the overall postoperative complication rate was lower in the ERAS group (RR: 0.76 [95% CI: 0.60, 0.97]), but there was no significant difference in the individual postoperative complication rate. Other indicators were also not statistically significant.

CONCLUSION

The combination of ERAS Program with laparoscopy surgery was safe and effective for the perioperative management of patients with distal gastric cancer.

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

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

The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Postoperative ileus is a frequent condition, leading to complications and a longer hospital stay. Few studies have demonstrated the benefit of early oral feeding in preventing ileus after gastrointestinal surgery. This study aims to evaluate the efficacy of early versus delayed oral feeding on the recovery of intestinal motility, length of hospital stay, and complications.

Methods

We conducted a systematic review and meta-analysis of randomized control trials, searching PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and the ClincalTrials.gov until 31 December 2022. We evaluated the first passage of the stool, the first flatus, complications, length of postoperative stay, and vomiting. We assessed the risk of bias using the Cochrane risk of bias tool (version 2) for randomized trials and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

Results

We included 34 studies with a median sample size of 102 participants. With a moderate certainty of the evidence, the early oral feeding may reduce the time taken for the first passage of the stool (MD -0.99 days; CI 95% -1.25, -0.72), the first flatus (MD -0.70 days; CI 95% -0.87, -0.53), and the risk of complications (RR 0.69; CI 95% 0.59-0.80), while with a low certainty of evidence, it may reduce the length of stay (MD -1.31 days; CI 95% -1.59, -1.03). However, early feeding likely does not affect the risk of vomiting (RR 0.90; CI 95% 0.68, 1.18).

Conclusion

This review suggests that early oral feeding after gastrointestinal surgery may lead to a faster intestinal recovery, shorter postoperative stays, and fewer complications. However, careful interpretation is needed due to high heterogeneity and the moderate-to-low quality of evidence. Future studies should focus on the type and starting time of early oral feeding.

Patient Experience Pre-Implementation of an Enhanced Recovery After Surgery Protocol: A Qualitative Investigation

Objective

This study explores the experience of adults undergoing major abdominal surgery pre-implementation of an Enhanced Recovery after Surgery program at a tertiary hospital in Melbourne, Australia, to enhance health promotion in Australian hospitals.

Methodology

Patients who were undergoing major abdominal surgery and who consented to participate were recruited in this study. Patients were chosen based on an inclusion-exclusion criterion. In-depth, semi-structured qualitative interviews were conducted by telephone and transcribed verbatim by the primary researcher. Thematic analysis was used and synthesised into five inductive themes. Eighteen participants aged between 51 and 82 years were interviewed. Codes were categorised into inductive themes: 1) preparedness for surgery; 2) communication; 3) aftercare; 4) expectations of surgery; and 5) overall experience utilising an iterative process. The following themes and subthemes emerged from the qualitative synthesis.

Results

Patients undergo a variety of experiences throughout the perioperative care period. Patient care and experience may be improved through increased access to patient engagement, information and communication, use of multimedia and teach-back method, optimization of the hospital environment and through providing adequate planning and support on discharge.

Conclusion

Evidence of barriers to enhancing patient surgical experience can be used to guide the implementation of Enhanced Recovery after Surgery protocols in Australian hospitals and therefore may limit its generalizability. This will improve health promotion as these findings provide valuable insights into integrative methods that can be considered to be important for achieving person-centred care. This knowledge can be useful in clinical practice, implementation and education programs for ERAS.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Effect of fast-track surgery on postoperative wound pain in patients with prostate cancer: A meta-analysis

Fast track surgery (FTS) is widely used in many procedures and has been shown to reduce complications and accelerate recovery. However, no studies have been conducted to assess their effectiveness in treating wounds after radical prostatectomy (RP). The objective of this study was to evaluate the impact of FTS on RP. We went through 4 major databases. A study was conducted by PubMed, the Cochrane Library, Embase, and the Web of Science to determine the effect of comparison of FTS versus conventional surgery in RP on postoperative wound complications as of 1 July 2023. Based on the review of literature, data extraction and literature quality assessment, we conducted meta-analyses with RevMan 5.3. In the course of the study, the researchers selected 6 of the 404 studies to be analysed according to exclusion criteria. Data analysis showed that the FTS method reduced the postoperative pain associated with VAS and also decreased the rate of postoperative complications in post-surgical patients. However, there was no significant difference between FTS and conventional surgery in terms of blood loss, operation time, and postoperative infection rate. Therefore, generally speaking, FTS has less impact on postoperative complications in patients with minimal invasive prostatic cancer, but it does reduce postoperative pain and total postoperative complications.

The effect of acupuncture on recovery after colorectal cancer resection: A systematic review meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the efficacy and safety of acupuncture by systematically reviewing the literature on colorectal cancer resection.

METHODS

Seven electronic databases were searched from inception to February 28, 2023. Randomized controlled trials on acupuncture in patients after CRC resection were included. Two reviewers independently selected relevant trials, extracted data, and assessed the risk of bias. A random-effects meta-analysis model was used to obtain summary effect estimates. The data were pooled and analyzed using RevMan 5.3. The heterogeneity of selected studies was evaluated by evaluating the I-squared (I2) statistics.

RESULTS

Twenty-two studies with 1878 patients were included. Results of the meta-analysis showed there was a low level evidence that acupuncture may improve early postoperative symptoms, such as time to first flatus (n = 876, MD -0.77h, 95% CI -1.22 to -0.33 h, I2 = 89%), time to first bowel movement (n = 671, MD -1.41h, 95% CI -2.20 to -0.63 h, I2 = 95%), time to first defecation (n = 556, MD -1.03h, 95% CI -1.88 to -0.18 h, I2 = 95%), and nausea/vomiting (n = 1488, RR 0.72, 95% CI 0.59-0.89, I2 = 49%) compared with usual care and sham acupuncture. However, there were no statistically significant differences in postoperative pain (n = 1188, MD-0.21, 95% CI -0.59 to 0.17, I2 = 74%). And there was no sufficient evidence of improving long-term functional outcomes. There was substantial heterogeneity across trials. The adverse events associated with acupuncture stimulation were minor in include studies.

CONCLUSION SUBSECTIONS

There is currently low-level evidence supporting the use of acupuncture on postoperative symptoms for patients after colorectal cancer resection. More investigations should be established based on the STRICTA statement strictly.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement

OBJECTIVE

We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP.

METHODS

From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss.

RESULTS

A total of 75 pediatric patients (0-14 years) were included. The mean POS was 2.4 ± 1.4 days, shorter than that in recent studies in China (3.3 ± 1.4 days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4 min, and blood loss was 11.8 ± 10.0 ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05).

CONCLUSION

The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.

Laparoscopic transversus abdominis plane block is useful in pain relief after laparoscopic stapled repair of diastasis recti and ventral hernia

Background

There is still no consensus on perioperative pain control techniques in patients undergoing laparoscopic surgery; protocols of conventional therapy can be improved by the use of perioperative anaesthesiologic techniques, such as epidural or loco-regional analgesic administration as transversus abdominis plane (TAP) block. The aim of this evaluation was to investigate the role of laparoscopic-assisted TAP block during repair of diastasis recti associated with primary midline hernias in term of post-operative pain relief.

Materials

and

Methods

This was a retrospective evaluation of a prospectively maintained database including patients undergoing laparoscopic repair of diastasis recti associated with primary ventral hernia. Patients were divided into two groups: Group A patients (n = 34) received laparoscopic-assisted bilateral TAP-block of 7.5 mg/ml ropivacaine for each side and Group B patients (n = 29) received conventional post-operative therapy. All patients received 24 h infusion of 20 mg morphine; pain was checked at 6, 24 and 48 h after surgery by numeric rating scale (NRS) score. A rescue analgesia by was given if NRS score was >4 or on patient request.

Results

No differences in operative time, complications and post-operative stay, no complications related to TAP-block technique were found. Post-operative pain scores (determined by NRS) were found to be significantly different between groups. Group A patients showed a significant reduction in NRS score at 6, 24 and 48 h (P < 0.005) and in the number of patients requiring further analgesic drugs administration (P < 0.005) compared to Group B patients.

Conclusions

Laparoscopic-guided TAP-block can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic repair of diastasis recti and ventral hernias. The non-randomised nature of the study and the lack of a consistent series of patients require further evaluations.

Association of Hospital Bed Turnover With Patient Outcomes in Digestive Surgery

To determine the influence of hospital bed turnover rate (BTR) on the occurrence of complications following minor or major digestive surgery.

Background

Performance improvement in surgery aims at increasing productivity while preventing complications. It is unknown whether this relationship can be influenced by the complexity of surgery.

Methods

A nationwide retrospective cohort study was conducted, based on generalized estimating equation modeling to determine the effect of hospital BTR on surgical outcomes, adjusting for patient mix and clustering within 631 public and private French hospitals. All patients who underwent minor or major digestive surgery between January 1, 2013 and December 31, 2018 were included. Hospital BTR was defined as the annual number of stays per bed for digestive surgery and categorized into tertiles. The primary endpoint was a composite measurement of events occurring within 30 days after surgery: inpatient death, extended intensive care unit (ICU) admission, and reoperation.

Results

Rate of adverse events was 2.51% in low BTR hospitals versus 2.25% in high BTR hospitals for minor surgery, and 16.79% versus 16.83% for major surgery. Patients who underwent minor surgery in high BTR hospitals experienced lower complications (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97; P = 0.009), mortality (OR, 0.87; 95% CI, 0.78-0.98, P = 0.02), ICU admission (OR, 0.83; 95% CI, 0.70-0.99; P = 0.03), and reoperation (OR, 0.91; 95% CI, 0.85-0.97; P = 0.002) compared to those in low BTR hospitals. Such differences were not consistently observed among patients admitted for major surgery.

Conclusions

High turnover of patients in beds is beneficial for minor procedures, but questionable for major surgeries.

The application of enhanced recovery after surgery in minimally invasive gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to investigate the efficacy and safety of enhanced recovery after surgery (ERAS) for patients with gastric cancer undergoing minimally invasive surgery (MIS).

METHODS

We searched the PubMed, Cochrane Library, Web of Science, Embase, CNKI, VIP, WanFang, and CBM for relevant RCTs from the database inception until December 2021, for studies that compared the ERAS and traditional care (TC) in MIS for gastric cancer.

RESULTS

A total of 25 RCTs comprising 2809 patients were included in this study. When compared with the traditional care TC group, the ERAS group had a shorter postoperative hospital stay [MD = -1.88,95%CI (-2.22, -1.55), P < 0.00001] and an earlier time at first postoperative flatus [MD = -18.12,95%CI (-21.45,-14.80), P < 0.00001] along with lower medical costs [SMD = -0.64, 95% CI (-0.85, -0.43), P < 0.00001] and an overall reduction in postoperative complication rates [RR = 0.55, 95% CI (0.44, 0.69), P < 0.00001]. However, the difference in the readmission rates    was not significant.

CONCLUSIONS

ERAS can shorten the postoperative hospital stay, hasten the first postoperative flatus and reduce medical costs and overall postoperative complication rate without increasing readmission rates. Therefore, the ERAS protocol is preferable for gastric cancer patients undergoing MIS.

Knowledge of enhanced recovery after surgery and influencing factors among abdominal surgical nurses: a multi-center cross-sectional study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are well established. Evidence describing nurses' knowledge of ERAS is limited.

AIM

To assess surgical nurses' knowledge of ERAS and identify factors that correlate with knowledge level.

DESIGN

An anonymous cross-sectional survey via an online social platform was conducted in the abdominal surgical specialty of 40 hospitals in ten cities in China.

METHODS

Nurses of abdominal surgery in hospitals were enrolled in this study. A self-administered questionnaire that was reviewed by an expert panel was used to assess the knowledge of ERAS in nurses. A generalised linear regression analysis was used to assess factors associated with nurses' knowledge regarding ERAS.

RESULTS

Overall survey participation was 91.8% (2230/2430). The mean score of ERAS-related knowledge among abdominal surgical nurses was 12.10 (SD = 3.79). ERAS knowledge differed according to gender, age, education level, professional title, years of working, specialised working years, ERAS training experience, surgical department, and type of hospital (p < 0.05).

CONCLUSIONS

Chinese nurses employed in abdominal surgical services need to improve the knowledge about ERAS protocols. Standardised training is recommended to improve nurses' ERAS-related knowledge, which can help nurses improve the quality of perioperative care and promote the recovery of patients.

Laparoscopic-Guided Ropivacaine Trocar-Site Infiltration Can Improve Post-Operative Pain Control after Laparoscopic Adrenalectomy

BACKGROUND

There is no consensus on pain control in patients undergoing laparoscopy; nowadays, conventional therapy may be improved by transversus abdominis plane block. The aim of this evaluation is to investigate the role of laparoscopic-assisted trocar-site ropivacaine infiltration during adrenalectomy in pain control.

METHODS

This is a retrospective evaluation of a prospectively maintained database including patients undergoing adrenalectomy. Patients were divided into 2 groups: Group A patients received laparoscopic-assisted trocar-site infiltration of 7.5 mg/mL ropivacaine and Group B patients did not receive any infiltration. All patients received a 24-hour infusion of 20 mg morphine; pain was checked at 6, 24, and 48 hours after surgery by Visual Analogue Scale (VAS) score. A rescue analgesia by was given if VAS score was > 4 or on patient request.

RESULTS

No differences in operative time, complications, and post-operative stay and no complications related to trocar-site infiltration were found. 6-hour and 48-hour VAS scores were not found to be significantly different between groups, even if a slight decrease in VAS score in Group A was reported. Group A showed significant reduction in VAS score at 24 hours (2.44 +/- .41 vs 3.01 +/- .78, P < .005) and in the number of patients requiring further analgesic drugs administration (40.6% vs 57.8%, P < .005).

CONCLUSIONS

Laparoscopic-guided trocar-site ropivacaine infiltration can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic adrenalectomy. The retrospective nature of the study and the lack of a consistent series of patients require further evaluations.

Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: ERAS for Patients Undergoing Cytoreductive Surgery with or Without HIPEC

ERAS protocols may reduce length of stay and return to full functional recovery after cytoreductive surgery and HIPEC. Prehabilitation programs and post-operative goal directed pathways, along with other essential components of ERAS are discussed with supporting evidence.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]

INTRODUCTION

Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment.

METHODS

Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment.

RESULTS

The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions.

CONCLUSION

Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China

BACKGROUND

Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function.

METHODS

This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators.

RESULTS

The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023).

CONCLUSION

Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.

Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas

INTRODUCTION

Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear.

AREAS COVERED

This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications.

EXPERT OPINION

No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.

Impact of enhanced recovery after surgery or fast track surgery pathways in minimally invasive radical prostatectomy: a systematic review and meta-analysis

Background

The enhanced recovery after surgery (ERAS) and fast track surgery (FTS) protocols have been applied to a variety of surgeries and have been proven to reduce complications, accelerate rehabilitation, and reduce medical costs. However, the effectiveness of these protocols in minimally invasive radical prostatectomy (miRP) is still unclear. Thus, this study aimed to evaluate the impact of ERAS and FTS protocols in miRP.

Methods

We searched PubMed, Cochrane Library, Embase, and Web of Science databases to collect randomized and observational studies comparing ERAS/FTS versus conventional care in miRP up to July 1, 2019. After screening for inclusion, data extraction, and quality assessment by two independent reviewers, the meta-analysis was performed with the RevMan 5.3 and STATA 15.1 software. Results were expressed as risk ratio (RR) and weighted mean difference (WMD) with 95% confidence intervals (CIs).

Results

In total, 11 studies involving 1,207 patients were included. Pooled data showed that ERAS/FTS was associated with a significant reduction in length of stay (LOS) (WMD: -2.41 days, 95% CI: -4.00 to -0.82 days, P=0.003), time to first anus exhaust (WMD: -0.74 days, 95% CI: -1.14 to -0.34 days, P=0.0003), and lower incidence of postoperative complications (RR: 0.70, 95% CI: 0.53 to 0.92, P=0.01). No significant differences were found between groups for operation time, estimated blood loss, postoperative pain, blood transfusion rate, and readmission rate (P>0.01).

Conclusions

Our meta-analysis suggests that the ERAS/FTS protocol is safe and effective in miRP. However, more extensive, long-term, prospective, multicenter follow-up studies, and randomized controlled trials (RCTs) are required to validate our findings.

Recovery after laparoscopic parastomal hernia repair

BACKGROUND

The perioperative care and postoperative period after laparoscopic hernia repair have not been well described. The aim of this study was to describe the postoperative course after laparoscopic parastomal hernia repair.

METHODS

This was a prospective cohort study including consecutive patients undergoing laparoscopic parastomal hernia repair. The outcomes of interest were patient-reported pain, nausea and fatigue, time to stoma function, length of stay (LOS), use of transversus abdominis plane (TAP) block and epidural analgesia, the cumulative dose of morphine equivalent analgesics during the first 5 postoperative days, and postoperative complications.

RESULTS

Forty patients were included, 20% had ileostomy and 80% colostomy. The mesh was placed according to Sugarbaker (87.5%) and keyhole (12.5%) technique. Twenty-two patients (55%) required peripheral nervous blockades postoperatively. The median number of days to stoma function was 3 days (range 2-3.8). The mean cumulative dose of morphine equivalent analgesics was 21.9 mg on the day of surgery, 27.8 mg on the first postoperative day (POD1), 23.9 on POD2, 17.3 mg on POD3, 15.3 mg on POD4, 8.9 mg on POD5, and 115.2 mg in total. The median LOS was 4 days (range 3-6). The incidence of postoperative complications was 25%.

CONCLUSION

Laparoscopic parastomal hernia repair carried a high risk of complications. Further, analgesic treatment after surgery was insufficient, with high opioid requirements postoperatively, and more than half of the patients required peripheral nervous blockades, indicating that postoperative pain is a major issue in this patient group. Improved postoperative care for these patients is required.