Enhanced recovery after surgery (ERAS) versus standard recovery for elective gastric cancer surgery: A meta-analysis of randomized controlled trials

Optimizing postsurgical recovery for elderly patients with gastric cancer

Based on a recent study by Li et al, this editorial examines the significance of enhanced recovery after surgery (ERAS) protocols for elderly patients with gastric cancer. Cancer-related mortality, which is overwhelmingly caused by gastric cancer, calls for effective treatment strategies. Despite advances in the field of oncology, conventional postoperative care often results in prolonged hospital stays and increased complications. The aim of ERAS is to expedite recovery, reduce surgical stress, and improve patient satisfaction. The study of Li et al showed that, compared to traditional care, ERAS significantly reduces mortality risk, shortens hospital stays, and decreases postoperative complications. These findings support the widespread implementation of ERAS protocols in surgical practice to enhance patient outcomes and healthcare value.

Enhanced recovery after surgery-based nursing in older patients with postoperative intestinal obstruction after gastric cancer surgery: A retrospective study

BACKGROUND

Gastric cancer-related morbidity and mortality rates are high in China. Patients who have undergone gastric cancer surgery should receive six cycles of chemotherapy according to their condition. During this period, intestinal obstruction is likely to occur. Electrolyte balance disorders, peritonitis, intestinal necrosis, and even hypovolemic shock and septic shock can seriously affect the physical and mental recovery of patients and threaten their health and quality of life (QoL).

AIM

To quantitatively explore the effects of enhanced recovery after surgery (ERAS)–based nursing on anxiety, depression, and QoL of elderly patients with postoperative intestinal obstruction after gastric cancer.

METHODS

The clinical data of 129 older patients with intestinal obstruction after gastric cancer surgery who were treated and cared for in our hospital between January 2019 and December 2021 were examined retrospectively. Nine patients dropped out because of transfer, relocation, or death. According to the order of admissions, the patients were categorized into either a comparison group or an observation group according to the random number table, with 60 cases in each group.

RESULTS

After nursing care, the observation group required significantly less time to eat for the first time, recover bowel sounds, pass gas, and defecate than the comparison group (P < 0.05). No significant difference was noted in nutrition-related indicators between the two groups before care. Before care, the Symptom Check List-90 scores between the two groups were comparable, whereas anxiety, depression, paranoia, fear, hostility, obsession, somatization, interpersonal sensitivity, and psychotic scores were significantly lower in the observation group after care (P < 0.05). The QoL scores between the two groups before care did not differ significantly. After care, the physical, social, physiological, and emotional function scores; mental health score; vitality score; and general health score were significantly higher in the observation group, whereas the somatic pain score was significantly lower in the observation group (P < 0.05).

CONCLUSION

ERAS-based nursing combined with conventional nursing interventions can effectively improve patient’s QoL, negative emotions, and nutritional status; accelerate the time to first ventilation; and promote intestinal function recovery in elderly patients with postoperative intestinal obstruction after gastric cancer surgery.

Application of the quality of recovery-40 questionnaire to evaluate the effectiveness of enhanced recovery after surgery protocols in gastric cancer

Patient reported outcomes is currently considered to be an important supplement to evaluate the effectiveness of enhanced recovery after surgery (ERAS) clinical practice. The Quality of Recovery-40 Questionnaire (QoR-40) is one of the most frequently used and validation tool to assess the subjective feelings of quality of life after surgery. The present study aimed to use the QoR-40 to evaluate the effectiveness of ERAS protocols in gastric cancer from the perspective of patient-reported quality of recovery. The study was designed as a prospective, non-randomized clinical trial, conducted in a single center. Patients in our hospital who were scheduled to undergo radical surgery for gastric cancer were divided into ERAS group and control group (Contr group). The QoR-40 were administered one day before surgery (Baseline) and on postoperative day 1, 3, 6, and 30. The difference in QoR-40 scores between the ERAS and Contr groups was compared by repeated-measures ANOVA. A total of 200 patients completed the study, including 100 patients in the ERAS group and 100 patients in the Contr group. The Baseline time point QoR-40 scores of the ERAS and Contr groups were 179.68 ± 14.46 and 180.12 ± 17.12, respectively, and no significant difference was noted between the two groups (p = 0.845). The postoperative QoR-40 score of the ERAS group was significantly higher than that of the Contr group, and the difference was statistically significant (p = 0.006). This study demonstrated that, in terms of patient-reported quality of recovery, the postoperative recovery effect of ERAS protocols in gastric cancer is significantly better than that of the traditional treatment model.

Implementing Enhanced Recovery After Surgery for hysterectomy in a hospital network with audit and feedback: A stepped-wedge cluster randomised trial

OBJECTIVE

To evaluate the effectiveness of implementing the Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing elective hysterectomy in a network of regional hospitals, supported by an intensive audit-and-feedback (A&F) approach.

DESIGN

A multi-centre, stepped-wedge cluster randomised trial (ClinicalTrials.gov NCT04063072).

SETTING

Gynaecological units in the Piemonte region, Italy.

POPULATION

Patients undergoing elective hysterectomy, either for cancer or for benign conditions.

METHODS

Twenty-three units (clusters), stratified by surgical volume, were randomised into four sequences. At baseline (first 3 months), standard care was continued in all units. Subsequently, the four sequences implemented the ERAS protocol successively every 3 months, after specific training. By the end of the study, each unit had a period in which standard care was maintained (control) and a period in which the protocol, supported by feedback, was applied (experimental).

MAIN OUTCOME MEASURES

Length of hospital stay (LOS), without outliers (>98th percentile).

RESULTS

Between September 2019 and May 2021, 2086 patients were included in the main analysis with an intention-to-treat approach: 1104 (53%) in the control period and 982 (47%) in the ERAS period. Compliance with the ERAS protocol increased from 60% in the control period to 76% in the experimental period, with an adjusted absolute difference of +13.3% (95% CI 11.6% to 15.0%). LOS, moving from 3.5 to 3.2 days, did not show a significant reduction (-0.12 days; 95% CI -0.30 to 0.07 days). No difference was observed in the occurrence of complications.

CONCLUSIONS

Implementation of the ERAS protocol for hysterectomy at the regional level, supported by an A&F approach, resulted in a substantial improvement in compliance, but without meaningful effects on LOS and complications. This study confirms the effectiveness of A&F in promoting important innovations in an entire hospital network and suggests the need of a higher compliance with the ERAS protocol to obtain valuable improvements in clinical outcomes.

Short- and Long-Term Advantages of Laparoscopic Gastrectomy for Elderly Patients with Locally Advanced Cancer

Minimally invasive surgery has provided several clinical advantages in locally advanced gastric cancer (LAGC) care, although a consensus on its application criteria remains unclear. Surgery remains a careful choice in elderly patients, who frequently present with frailty, comorbidities, and other disabling diseases. This study aims to assess the possible advantages of laparoscopic gastric resections in elderly patients presenting with LAGC. This retrospective study analyzed a single-center series of elderly patients (≥75 years) undergoing curative resections for LAGC between 2015 and 2020. A comparative analysis of open versus laparoscopic approaches was conducted, focusing on postoperative complications, length of hospital stay (LOS), and long-term survival. A total of 62 patients underwent gastrectomy through an open or a laparoscopic approach (31 pts each). The study population did not show statistically significant differences in demographics, operative risk, and neoadjuvant chemotherapy. The laparoscopic group reported significantly minimized overall complications (45.2 vs. 71%, p = 0.039) and pulmonary complications (0 vs. 9.7%, p = 0.038) as well as a shorter LOS (8 vs. 12 days, p = 0.007). Lymph node harvest was equal between the groups, although long-term overall survival presented significantly better after laparoscopic gastrectomy (p = 0.048), without a relevant difference in terms of disease-free and disease-specific survivals. Laparoscopic gastrectomy proves effective in elderly LAGC patients, offering substantial short- and long-term postoperative benefits.

Excessive Preoperative Testing in Otolaryngology: A Retrospective Comparison of Primary Care and Perioperative Providers

OBJECTIVE

To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing.

STUDY DESIGN

Cross-sectional study.

SETTING

Academic medical center.

METHODS

Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables.

RESULTS

Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing.

CONCLUSION

Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.

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.

ERAS following Gastrectomy for Octo- and Nonagenarians: A Single-Center Retrospective Analysis

Background: The safety and efficacy of enhanced recovery after surgery (ERAS) following elective gastrectomy for gastric cancer in patients >80 years of age are not well described. The aim of this study was to explore whether an ERAS protocol following gastrectomy in this age group can be safely implemented and reduce postoperative length of stay. Methods: A retrospective, single-center analysis was performed. All patients >80 years of age with gastric cancer undergoing elective subtotal and total gastrectomy between January 2010 and December 2021 were identified. With the implementation of an ERAS protocol in January 2016, patients treated beforehand were allocated to Group A (pre-ERAS) and Group B (ERAS). The length of stay, incidence of postoperative complications and representation/readmission to the hospital were compared between the groups. Results: Of the 221 patients identified, 56 met the inclusion criteria with 22 patients (39.3%) allocated to Group A and 34 patients (60.7%) to Group B. There were no differences with regard to the type of resection and surgical approach. Length of stay was shorter in Group B (5 days, range 2-27 versus 10 days, 3-109, P = .040). A trend toward more discharges by postoperative day 3 was noted among patients in Group B (7/34, 20.6% versus 2/22, 9.1%, P = .253). There were no differences in the incidence of postoperative complications or readmission hospital between the groups. Conclusion: Among patients >80 years of age, ERAS following gastrectomy for cancer is associated with a reduced length of stay and can be safely implemented.

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.

Relation between frailty and adverse outcomes in elderly patients with gastric cancer: a scoping review

Background

Playing an exemplary role, frailty have crucial effect on the preoperative evaluation of elderly patients. Previous studies have shown that frailty is associated with complications and mortality in patients with gastric cancer (GC). However, with the development of the concept of "patient-centered", the range of health-related outcomes is broad. The differences in relation between frailty and various adverse outcomes will be further explored.

Method

The PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases were searched for keywords, including frailty (such as frail) and gastric cancer (such as stomach neoplasms or stomach cancer or gastrectomy or gastric surgery). The search period is until August 2023. The included studies were observational or cohort studies with postoperative related adverse outcomes as primary or secondary outcome measures. Valid assessment tools were used. The Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess methodological quality in the included literature.

Result

Fifteen studies were included, including 4 cross-sectional studies, 8 retrospective cohort studies, and 3 prospective cohort studies. Among them, 6 studies were rated as "Good" and 9 studies were rated as "Fair," indicating that the quality of the literature was high. Then, 10 frailty assessment tools were summarized and classified into two broad categories in accordance with frailty models. Results of the included studies indicated that frailty in elderly patients with GC was associated with postoperative complications, mortality, hospital days, readmissions, quality of life, non-home discharge, and admission to the intensive care unit.

Conclusion

This scoping review concludes that high levels of preoperative frailty increase the risk of adverse outcomes in elderly patients with GC. Frailty will be widely used in the future clinical evaluation of elderly gastric cancer patients, precise risk stratification should be implemented for patients, and frailty management should be implemented well to reduce the occurrence of adverse treatment outcomes.

Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.

Effects of the enhanced recovery after surgery (ERAS) protocol on the postoperative stress state and short-term complications in elderly patients with colorectal cancer

OBJECTIVE

The aim of this study was to evaluate the feasibility and necessity of enhanced recovery after surgery in elderly patients with colorectal cancer by observing inflammatory markers and postoperative complications.

METHODS

Hospitalized colorectal cancer patients from the Affiliated Hospital of Jiangsu University from January 2021 to September 2022 were included in the study and divided into two groups: Enhanced Recovery After Surgery (ERAS) and non-ERAS. Data on postoperative inflammatory markers and complications were also collected.

RESULTS

A total of 313 patients with colorectal cancer were included: 182 in the ERAS group and 131 in the non-ERAS group. The patients in the ERAS group had significantly shorter days of postoperative hospitalization, urinary catheter and drainage tube withdrawal times, and recovery of bowel function (P < .05) than those of the non-ERAS group. Moreover, the ERAS group had lower hospitalization expenses than those of the non-ERAS group (P < .05). However, the procalcitonin and tumor necrosis factor (TNF)-α levels in the ERAS group was significantly lower than those in the non-ERAS group on postoperative days 1 and 3 (P < .05), and the interleukin (IL)-6 and IL-10 levels in the ERAS group were significantly lower than those in the non-ERAS group on the 1st, 3rd, and 5th postoperative days (P < .05). The C-reactive protein (CRP) and white blood cell (WBC) levels in the ERAS group were lower than those in the non-ERAS group on postoperative days 3 and 5 (P < .05). However, the hemoglobin levels did not differ significantly (P > .05). The albumin levels did not differ significantly between the two groups before surgery (P > .05); however, the albumin level in the ERAS group was higher than that in the non-ERAS group on postoperative days 3 and 5 (P < .05). The ERAS patients had lower albumin levels after surgery than those of the non-ERAS patients (P < .05).

CONCLUSION

ERAS leads to a series of perioperative optimization measures, thereby reducing the postoperative stress response in elderly patients with colorectal cancer and the occurrence of perioperative complications.

Association of Malnutrition Diagnosed Using Global Leadership Initiative on Malnutrition Criteria with Severe Postoperative Complications After Gastrectomy in Patients with Gastric Cancer

Background: The purpose of this study was to investigate the relationship between malnutrition assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria and the occurrence of severe postoperative complications (SPCs) after gastrectomy in patients with gastric cancer. Methods: A total of 220 patients with gastric cancer were included in this retrospective study. According to the GLIM criteria, the first step was to use the Nutrition Risk Screening Score 2002 to conduct nutritional risk screening for patients and the second step was to diagnose and grade the severity of malnutrition in patients at risk of malnutrition. According to the Clavien-Dindo classification system, SPCs were defined as C-D Grade IIIa or higher. Results: Overall, 66 (30.0%) patients were diagnosed with malnutrition, including 32 (14.5%) with moderate malnutrition and 34 (15.5%) with severe malnutrition. The incidence of SPCs was 14.5%, and the most frequent postoperative event was anastomotic leakage. In the multivariate regression analysis, malnutrition was considered an independent risk factor for SPCs (P < .001). After adjusting for various factors, the grading association remained statistically significant. Compared with patients with normal nutrition, patients with moderate and severe malnutrition have a nearly 15-fold (OR = 15.682, 95% CI: 4.481-54.877, P < .001) and 20-fold (OR = 20.554, 95% CI: 5.771-73.202, P < .001) increased risk of developing SPCs, respectively. Conclusions: Malnutrition assessed by GLIM was an independent risk factor for SPCs in gastric cancer patients. Therefore, early identification of malnourished patients is crucial for timely implementation of nutritional treatment and reducing the occurrence of postoperative complications.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BACKGROUND

Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways.

AIM

To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters.

RESULTS

Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups.

CONCLUSION

ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.

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.

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.

Grip strength is an important predictor for nutritional risk and early postoperative ambulation in gastrointestinal tumors undergoing laparoscopic surgery: a prospective multicenter clinical study

BACKGROUND

Using grip strength as a predictor of nutritional risk and early ambulation for gastrointestinal tumor surgery and determining its critical value have not been reported. This study was designed to explore the influencing factors of early postoperative ambulation ability for patients with gastrointestinal tumors who underwent laparoscopic surgery.

METHODS

Four-hundred twenty-seven patients with gastrointestinal tumors who underwent laparoscopic surgery at three tertiary A hospitals in Beijing were prospectively enrolled. Subsequently, logistic regression analysis was conducted to determine the independent predictors of early postoperative ambulation. Logistic regression analyses for the different gender were also performed. In addition, the effectiveness of preoperative grip strength measurement in nutritional risk assessment was analyzed by using nutritional risk score 2002 (NRS 2002) as a control.

RESULTS

The included cases were comprised of 283 male and 144 female patients, with an age of 59.35 ± 11.70 years. Gender, preoperative grip strength, operative time, and number of indwelling tubes were independent predictors of early postoperative ambulation. In the male group, lower preoperative grip strength and more indwelling tubes were independent risk factors for early postoperative ambulation. In the female group, lower preoperative grip strength and extended operating time were independent risk factors. Moreover, preoperative grip strength (male < 32 kg, female < 21 kg) can be used as a risk predictor for both preoperative nutritional risk and early postoperative ambulation.

CONCLUSIONS

As a simple and objective measure of muscle strength, grip strength measurement is expected to be an effective predictor for both early postoperative ambulation ability and nutritional status of patients.

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.

Application effect of gastrointestinal bundle nursing on the protection of gastrointestinal function in patients with gastric cancer

Evidence-based nursing practice was used to formulate the enhanced recovery surgery bundle nursing strategy and apply it to patients with gastric cancer, to explore its safety, effectiveness and feasibility in perioperative gastrointestinal function protection in patients with gastric cancer. Selected the clinical medical records of 100 gastric cancer patients treated in our hospital from June 2019 to June 2021 as the research objects, and divided them into the control group and the observation group with 50 cases in each group according to the random number table. Among them, the control group was given routine nursing measures for nursing intervention, and the observation group was given gastrointestinal enhanced recovery surgery cluster nursing on the basis of the control group. The differences in stress response, gastrointestinal function protection, negative emotions and pain scores of gastric cancer patients before and after nursing were compared between the 2 groups. The postoperative bowel sounds recovery time, first anal exhaust, and first defecation time in the observation group were lower than those in the control group, and the differences were statistically significant (P < .05). Before nursing, there was no significant difference in the scores of stress response changes between the 2 groups (P > .05). After nursing, heart rate (HR), mean arterial pressure (MAP), norepinephrine (NE), and epinephrine (E2) in the observation group were lower than those in the control group, and the difference was statistically significant (P < .05). The pain scores of the 2 groups were significantly improved at different time points, and the observation group was significantly less than the control group, and the difference was statistically significant (P < .05). Gastrointestinal enhanced recovery surgery bundle nursing can effectively improve the gastrointestinal function of patients with gastric cancer, improve the emotional response and stress response of patients, and has certain reference value for the nursing of patients with gastric cancer.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Enhanced Recovery After Surgery Protocols for Head and Neck Cancer: Systematic Review and Meta-analysis

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction.

DATA SOURCES

PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators.

REVIEW METHODS

This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series.

RESULTS

Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; I2 = 0%; P < .00001) with the ERAS group as compared with non-ERAS controls. The standardized mean difference of the morphine milligram equivalent was 0.72 lower (95% CI, 0.26-1.18; I2 = 82%; P = .002) in the ERAS group vs controls. The quality of studies was moderate with a median MINORS score of 18.5 (range, 13.5-21.5).

CONCLUSION

Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.

Surgery-Related Muscle Loss after Pancreatic Resection and Its Association with Postoperative Nutritional Intake

To study the occurrence of surgery-related muscle loss (SRML) and its association with in-hospital nutritional intake, we conducted a prospective observational cohort study including patients who underwent pancreatic surgery because of (suspected) malignant diseases. Muscle diameter was measured by using bedside ultrasound 1 day prior to surgery and 7 days postoperatively. Clinically relevant SRML was defined as ≥10% muscle diameter loss in minimally one arm and leg muscle within 1 week after surgery. Protein and caloric intake was measured by nutritional diaries. The primary endpoint included the number of patients with SRML. Secondary endpoints included the association between SRML and postoperative nutritional intake. Of the 63 included patients (60.3% men; age 67.1 ± 10.2 years), a total of 24 patients (38.1%) showed SRML. No differences were observed in severe complication rate or length of hospital stay between patients with and without SRML. During the first postoperative week, patients with clinically relevant SRML experienced more days without any nutritional intake compared with the non-SRML group (1 [0-4] versus 0 [0-1] days, p = 0.007). Significantly lower nutritional intake was found in the SRML group at postoperative days 2, 3 and 5 (p < 0.05). Since this study shows that SRML occurred in 38.1% of the patients and most of the patients failed to reach internationally set nutritional goals, it is suggested that more awareness concerning direct postoperative nutritional intake is needed in our surgical community.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.

OBJECTIVE

We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.

METHODS

We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.

RESULTS

Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.

CONCLUSIONS

We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.

Did the ERAS Protocol Improve Our Results in Locally Advanced Gastric Cancer Surgery?

ERAS is a protocol consisting of multidisciplinary approaches, including patient education, fluid resuscitation, keeping patients' innormothermic state, early feeding, and mobilization. We aimed to present and compare the postoperative results of patients operated on due to locally advanced gastric cancer who received neoadjuvant therapy in two high-volume tertiary centers, and aimed to present that ERAS protocols can be applied with success without increasing the complication rate. This retrospective study consisted of two groups: a non-ERAS group and an ERAS group. The ERAS group consisted of 106 patients and the non-ERAS group consisted of 104 patients. The time to first flatus was shorter in the ERAS group compared with the non-ERAS group: 2.8 (1-5) and 3.5 (1-5, p = 0.008), respectively. The average stay at the hospital was 9 (7-22) days in thenon-ERAS group and 6.5 (5-14) days in the ERAS group. Readmission to the hospital within first 15 days after discharge was observed in one (%0.9) patient in the non-ERAS group and in four (%3.8) patients in the ERAS group. ERAS protocols contribute positively to the nutritional status of patients by reducing surgical stress and the rate of hospitalization, and reducing health costs. However, it appears to be associated with increased readmission rates.

Physical Effects, Safety and Feasibility of Prehabilitation in Patients Awaiting Orthotopic Liver Transplantation, a Systematic Review

Prehabilitation improves surgical outcomes in patients undergoing surgery. However, patients preparing for orthotopic liver transplantation (OLT) are physically “frail” and suffer from comorbidities that generally hamper physical activity. This systematic review aims to evaluate the physical effects, safety and feasibility of prehabilitation in OLT candidates. Relevant articles were searched, in Embase, Web of Science, Cochrane, Medline and Google Scholar, to December 2021. Studies reporting on specified preoperative exercise programs, including adult OLT candidates with end-stage liver disease, with a model for end-stage liver disease (MELD) score ≥12 or Child-Pugh classification B/C, were included. This resulted in 563 potentially eligible studies, out of which eight were selected for inclusion, consisting of 1,094 patients (male sex 68%; mean age 51–61 years; mean MELD score 12-21). Six of the included studies were classified as low-quality by the GRADE system, and three studies had high risk for ineffectiveness of the training program according to the i-CONTENT tool. Significant improvement was observed in VO2 peak, 6-minute walking distance, hand grip strength, liver frailty index and quality of life. Feasibility ranged from an adherence of 38%–90% in unsupervised-to &gt;94% in supervised programs. No serious adverse events were reported. In conclusion, prehabilitation in patients awaiting OLT appears to improve aerobic capacity, and seems feasible and safe. However, larger clinical trials are required to accurately examine the preoperative and postoperative effects of prehabilitation in this specific patient population.

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUND

Three-dimensional (3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach (CRS), but its clinical efficacy remains controversial.

AIM

To compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy (3DLAG) with open gastrectomy (OG) for CRS.

METHODS

The clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up, we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival (OS) rates were compared between the two groups.

RESULTS

Among 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score, initial disease state (benign or malignant), primary surgical anastomosis method, interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss (188.33 ± 191.35 mL vs 305.83 ± 303.66 mL; P = 0.045) and smaller incision (10.86 ± 3.18 cm vs 20.06 ± 5.17 cm; P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG (14.0 ± 7.17 vs 10.73 ± 6.82; P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups (1.56 ± 2.84 vs 2.35 ± 5.28; P = 0.413). The complication rate (8.3% vs 20.8%; P = 0.207) and intensive care unit admission rate (5.6% vs 14.5%; P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval (CI): 72.4%-95.6%] and 73.3% (95%CI: 60.0%-89.5%) respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3% (95%CI: 76.4%-99.8%) and 75.6% (95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups (P = 0.68).

CONCLUSION

Compared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.

Immunonutrition reduces complications rate and length of stay after laparoscopic total gastrectomy: a single unit retrospective study

BACKGROUND

Preoperative immunonutrition (IN) reduces the incidence of postoperative complications in malnourished patients undergoing upper gastrointestinal surgery. However, its effect in norm-nourished patients remains unclear. Furthermore, patients with gastric cancer undergoing laparoscopic total gastrectomy (LTG) are not routinely included in protocols of enhanced recovery after surgery (ERAS).

OBJECTIVE

The aim of this study was to investigate the effects of perioperative IN in patients undergoing laparoscopic total gastrectomy (LTG) within an established ERAS pathway.

METHODS

A comparative retrospective study of patients undergoing LTG, receiving an immune-enhancing feed plus maltodextrin load the day of surgery (Group A) versus patients who had the same operation but no IN nor fast track management (group B).

RESULTS

There were no significant differences in patient demographic characteristics between the two groups but the medium age of patients in group A was older. Thirty-days postoperative complications were respectively 8.7% in Group A and 33.3% in Group B (p 0.04). Mean and median LOS for Group A and B were also significantly different: 7.2 ± 4.4 vs 10.3 ± 5.4 and 7 vs 10 days respectively.

CONCLUSION

Preoperative IN associated with ERAS protocol in normo-nourished patient undergoing LTG seems to reduce postoperative complications. Reduction in LOS is possibly associated to the ERAS protocol. Clinical trial registration Clinical trials.gov: NCT05259488.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Strategies for optimal perioperative outcomes in gastric cancer

Cancer and surgery represent a major stress on the human body. Any condition that prevents patients from tolerating the physiological stress is a risk factor for poor outcome. There is a need to identify these impairments early in the process with a simple screening, followed by assessments that provide a holistic picture of the patient. The proposed path of multimodal prehabilitation acts synergistically with enhanced recovery after surgery care to achieve optimal patient outcomes.

Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery

PURPOSE

Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT).

METHODS

This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes.

RESULTS

Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p < 0.01).

CONCLUSION

Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.

Application of the Concept of Enhanced Recovery after Surgery in Total Laparoscopic Radical Gastrectomy

To explore the clinical effects of total laparoscopic radical gastrectomy under the guidance of the concept of enhanced recovery after surgery (ERAS). Fifty-five patients were perioperatively treated under the concept of ERAS (ERAS group), while the remaining 55 patients were treated under the traditional perioperative concept (control group). The operation time, intraoperative blood loss, the time of first anal exhaust and first postoperative off-bed activity, postoperative length of stay, and incidence of postoperative complications were recorded in both groups. The pain of patients was assessed using VAS system. The nausea and vomiting and abdominal distension were assessed using the NVDS and abdominal distension score, respectively, within 24 h after operation. The patient's daily living ability was evaluated by the ADL scale at 3 d after the operation. The time of first anal exhaust, the time of first postoperative off-bed activity time, and the postoperative in-hospital time were all significantly shorter in the ERAS group than those in the control group (P < 0.001). The VAS score in the ERAS group was significantly lower than that in the control group at 12 h, 24 h, 48 h, and 72 h after operation (P < .001). The ERAS group had significantly lower NVDS score and abdominal distension score than the control group (P < 0.001). The postoperative ADL score in the ERAS group was significantly higher than that in the control group (P < 0.001). ERAS during the perioperative period of total laparoscopic radical gastrectomy can promote the postoperative rehabilitation of patients and alleviate postoperative pain and gastrointestinal reactions, which is safe and effective.

Which patients with gastric cancer should be candidates for Enhanced Recovery After Surgery protocols?

The application of Enhanced Recovery After Surgery (ERAS) protocols for the various cancer surgeries is increasing. ERAS program is introduced to reduce surgery stress, accelerate the average length of postoperative functional recovery, and lower postoperative morbidity. The application of the ERAS protocols for gastric cancer has been assessed in several studies, and it has been reported that the ERAS protocol significantly improves recovery time in gastrectomy patients without significantly affecting complications.

Effect of single-incision laparoscopic distal gastrectomy guided by ERAS and the influence on immune function

Background

To evaluate the immune function of gastric cancer patients after single-incision laparoscopic distal gastrectomy (SIDG) or multiport laparoscopic distal gastrectomy (MLDG) guided by enhanced recovery after surgery (ERAS).

Methods

A retrospective cohort study was performed on 120 patients who underwent laparoscopic distal gastrectomy for gastric cancer. The patients were divided into two groups according to operation method: group A (MLDG) and group B (SIDG), both guided by ERAS concept. The indicators reflecting immune function and inflammation, such as CD3⁺, CD4⁺, CD8⁺ and NK cell count, CD4⁺/CD8⁺ cell ratios, IgA, IgM and IgG levels, C-reactive protein (CRP), total lymphocyte count (TLC) and neutrophil-to-lymphocyte ratio (NLR) were tested 3 days and 7 days after surgery.

Results

The skin incision length of patients in group B was significantly shorter than that in group A, but the operation time was significantly longer in group B than that in group A (P < 0.05). There were no significant differences in preoperative CD3+, CD4+, CD8+, natural killer (NK) cells, CD4+/CD8+, IgA, IgM and IgG levels between two groups (P < 0.05). Three days after surgery, the immune function indices were decreased in both groups, but with no significant difference between two groups (P > 0.05). On the 7th day after surgery, the immune indexes of both groups recovered somewhat, approaching the preoperative level (P > 0.05). Inflammation indexes increased 3 days after surgery and decreased 7 days after surgery in both groups, among them the CRP level in group A was higher than that in group B (P < 0.05). The 3-year survival rate were 96.7% in group A and 91.7% in group B, respectively, with no statistically significant difference.

Conclusion

Compared with MLDG guided by ERAS, SIDG under the guidance of the ERAS concept has better cosmetic effect and similar effect on immune function of gastric cancer patients.

Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity?

PURPOSE OF REVIEW

A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation.

RECENT FINDINGS

All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening.

SUMMARY

There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.

Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review

IMPORTANCE

Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction.

OBJECTIVE

To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS.

EVIDENCE REVIEW

Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide.

FINDINGS

Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days).

CONCLUSIONS AND RELEVANCE

This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer

BACKGROUND AND OBJECTIVES

The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer.

METHODS

We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications.

RESULTS

One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0]; p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar.

CONCLUSIONS

Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.

Application of and Clinical Research on Enhanced Recovery After Surgery in Perioperative Care of Patients With Supratentorial Tumors

PURPOSE

This study intends to explore the safety and effectiveness of the concept of enhanced recovery after surgery (ERAS) in the perioperative care of patients with supratentorial tumors.

METHODS

A total of 151 supratentorial tumor patients were enrolled in this study, and they were divided into control group (n = 75) and observation group (n = 76) according to the random number table method. Patients in the control group received routine neurosurgery care, and patients in the observation group received enhanced recovery after surgery care. The incidence of perioperative complications, postoperative hospital stays, early postoperative eating time, catheter removal time, and time to get out of bed were observed for the two groups of patients, and the quality of postoperative recovery was evaluated.

RESULTS

There was no statistically significant difference in the basic data of the two groups of patients, such as age, gender, lesion location, and condition (P>0.05), and they were comparable. The observation group's postoperative eating time, catheter removal time, and time to get out of bed were significantly earlier than those of the control group. Postoperative hospital stays and hospitalization expenses were less than those of the control group. There was a statistically significant difference in postoperative hospital stay between the two groups (P<0.05).

CONCLUSION

Applying the ERAS concept to implement perioperative care for patients with supratentorial tumors is safe and effective. It can not only reduce after-surgical stress and accelerate postoperative recovery, but also shorten hospital stays and reduce hospital costs. It is worthy of clinical application.

Nutritional management of gastric cancer

Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of "post-gastrectomy syndromes", the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 2): UPDATE ON TREATMENT

BACKGROUND

: The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented.

AIM

: To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment.

METHODS

To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation.

RESULTS

: Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3.

CONCLUSION

: The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

Implementation of an enhanced recovery protocol in gynecologic oncology

•

Enhanced recovery in gynecologic oncology decreased narcotic usage.

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Shorter length of hospital stay was also observed in the ERAS cohort.

•

ERAS produced early return of bowel function.

•

The ERAS cohort received less perioperative blood transfusions.

•

A compliance analysis is integral to successful implementation of ERAS.

Enhanced Recovery after Surgery (ERAS) is an evidence-based approach that aims to reduce narcotic use and maintain anabolic balance to enable full functional recovery. Our primary aim was to determine the effect of ERAS on narcotic usage among patients who underwent exploratory laparotomy by gynecologic oncologists. We characterized its effect on length of stay, intraoperative blood transfusions, bowel function, 30-day readmissions, and postoperative complications. A retrospective cohort study was performed at Abington Hospital-Jefferson Health in gynecologic oncology. Women who underwent an exploratory laparotomy from 2011 to 2016 for both benign and malignant etiologies were included before and after implementation of our ERAS protocol. Patients who underwent a bowel resection were excluded. A total of 724 patients were included: 360 in the non-ERAS and 364 in the ERAS cohort. An overall reduction in narcotic usage, measured as oral morphine milliequivalents (MMEs) was observed in the ERAS relative to the non-ERAS group, during the entire hospital stay (MME 34 versus 68, p < 0.001 and within 72 h postoperatively (MME 34 versus 60, p < 0.005). A shorter length of stay and earlier return of bowel function were also observed in the ERAS group. No differences in 30-day readmissions (p = 0.967) or postoperative complications (p = 0.328) were observed. This study demonstrated the benefits of ERAS in Gynecologic Oncology. A significant reduction of postoperative narcotic use, earlier return of bowel function and a shorter postoperative hospital stay was seen in the ERAS compared to traditional perioperative care.

Modified ileal conduit intracorporeally accomplished following laparoscopic radical cystectomy with enhanced recovery protocols: experience with 48 cases

Background

This study introduces the results of laparoscopic radical cystectomy with modified intracorporeal ileal conduit (mICIC), which was accompanied by enhanced recovery after surgery (ERAS) protocols.

Methods

From March 2014 to June 2020, 48 patients underwent mICIC. Patients were divided into ERAS (n=17) and non-ERAS groups (n=31). Baseline and perioperative variables were analyzed. The primary outcome was 90-day complications. Secondary outcomes were operative time, length of stay, two-year overall survival, cancer-specific survival, and disease-free survival.

Results

Forty-eight patients underwent intracorporeal ileal conduit with no transition to open surgery. Twenty-five patients (52.1%) experienced at least one complication, including 22 minor cases (45.8%) and three major cases (6.2%). The median operative time, urinary diversion time, estimated blood loss, and length of stay were 320 min, 135 min, 200 mL, and 10.5 days, respectively. The median time to flatus and normal diet were two days and three days, respectively. A comparison between ERAS and non-ERAS groups indicated that ERAS implementation was associated with less complications (29.4% vs. 64.5%, P=0.018), faster time to flatus (2 vs. 3 days, P=0.016) and liquid diet (2 vs. 4 days, P<0.001). The results of hydronephrosis and compromised renal function showed no difference between the preoperative period and six months after surgery. The mean follow-up time was 25.4 months, and the two-year overall survival, cancer-specific survival, and disease-free survival rates were 61.3%, 73.2%, and 58.4%, respectively.

Conclusions

The complication rate and operative time of the mICIC were acceptable. Clinical outcomes can be optimized with ERAS pathway.

Oral Pregabalin in Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Pregabalin has received wide clinical attention as a new type of analgesic. We undertake a systematic review and meta-analysis to evaluate the effect of pregabalin on postoperative pain in patients undergoing cardiac surgery.

Methods

We searched PubMed, Embase, and Cochrane Library (from inception to July 2020) for eligible studies. The primary outcomes were the total morphine consumption at 24 h. A secondary outcome was intraoperative fentanyl consumption, extubation time postoperative, and length of stay in hospital. We calculated pooled weighted mean difference (WMD) or odds ratio (OR) and 95% CIs using random- or fixed-effects models.

Results

Seven trials involving 463 patients were listed. Meta-analysis showed that the total morphine consumption at 24 h in the pregabalin group was significantly less than the control group (WMD: -5.44, 95% CI: -10.42–0.46, P = 0.03). We found that there is no significant difference between the two groups in intraoperative fentanyl consumption. Compared with the control group, the length of stay in hospital in the pregabalin group was significantly shorter (WMD = -0.87, 95% CI: -1.42−0.32, P = 0.002). And we found that there were no significant differences between the two groups in extubation time (WMD: 17.24, 95% CI: -24.36−58.84, P = 0.42).

Conclusions

Oral pregabalin for cardiac surgery patients can effectively reduce the patient's 24-hour morphine consumption after surgery, shorten the patient's hospital stay, and is more conducive to early postoperative recovery.

Progress of Gastric Cancer Surgery in the era of Precision Medicine

With the development of genomics, the update of modern imaging technology and the advent of artificial intelligence and big data, the surgical treatment of gastric cancer has gradually stepped into precision medicine. Precision surgery treatment of gastric cancer is based on accurate molecular typing and staging using modern molecular diagnostic technology and imaging, and the formulation of precise and individualized surgical treatment plans, with the concept of minimally invasive and accelerated rehabilitation surgery running through it. For intermediate-stage gastric cancer, we have adopted a comprehensive treatment approach including traditional radiotherapy and chemotherapy, targeted therapy and immunotherapy. Utilize artificial intelligence and big data technology to improve the standardization and interconnectivity of specialty data and realize the transformation of evidence-based medicine. Promoting the standardization, standardization and individualization of gastric cancer surgical treatment, providing patients with precise diagnosis and treatment, and further improving patients' prognosis are the opportunities and challenges in the development of gastric cancer surgery.

[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.

Nutritional management of gastric cancer

Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs (Enhanced Recovery after Surgery) is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of «post-gastrectomy syndromes», the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis

INTRODUCTION

Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

OBJECTIVE

To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

METHODS

We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

RESULTS

18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

CONCLUSION

There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

The Effect of an Enhanced Recovery Protocol on Colorectal Surgery Patients With Diabetes

BACKGROUND

The effect of an enhanced recovery protocol including preoperative carbohydrate loading on patients with diabetes is unclear. This study investigated the effect of both on perioperative glucose management and postoperative outcomes in patients with diabetes undergoing colorectal surgery.

MATERIALS AND METHODS

A retrospective study was conducted on patients undergoing elective colorectal surgery before and after implementation of an enhanced recovery protocol. Ninety-nine patients with type 2 diabetes (DM, 41 control versus 58 enhanced recovery) and 366 patients without diabetes (NDM, 158 control versus 158 enhanced recovery) were included. Multivariate analyses were run to compare mean peak perioperative serum glucose and postoperative outcomes in enhanced recovery and control cohorts with (DM) and without diabetes (NDM).

RESULTS

Mean peak preoperative glucose was elevated in DM enhanced recovery compared with DM control patients (192.2 [72.2] versus 139.8 [41.4]; P < 0.001). Mean peak intraoperative (162.3 [43.1] versus 163.8 [39.6]; P = 0.869) and postoperative glucose (207.7 [75.8] versus 217.8 [78.5]; P = 0.523) were similar in DM enhanced recovery compared with DM control group. Enhanced recovery led to decreased LOS in DM (P = 0.001) and NDM enhanced recovery patients (P < 0.000) compared with their control groups.

CONCLUSIONS

An enhanced recovery protocol may lead to increased peak preoperative glucose levels and 30-d readmissions in patients with type 2 diabetes undergoing colorectal surgery. However, the ultimate clinical significance of transiently elevated preoperative glucose in DM patients is uncertain. Our results suggest that an enhanced recovery protocol and preoperative carbohydrate loading does not lead to poorer postoperative glycemic control overall in patients with diabetes undergoing colorectal surgery.