Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Perioperative risk factors for prognosis in patients undergoing radical esophagectomy: A retrospective study

BACKGROUND

Esophageal cancer constitutes one of the most aggressive malignant neoplasms associated with poor clinical outcomes. While surgical resection remains the cornerstone of curative intervention, optimization of perioperative care protocols has emerged as an essential strategy to reduce postoperative complications and potentially improve long-term survival rates in patients undergoing esophagectomy. However, substantial debate persists regarding the relative importance of various perioperative risk factors and their impact on post-resection outcomes.

AIM

To identify perioperative factors affecting prognosis after radical esophagectomy, aiming to improve patient outcomes through targeted interventions.

METHODS

A retrospective study analyzed 378 patients with esophageal cancer who underwent radical esophagectomy (McKeown, Sweet, or Ivor-Lewis procedures) from January 2022 through December 2023. All operations were performed by experienced surgeons following standardized perioperative protocols. The investigation gathered data on patient demographics, surgical parameters, tumor pathology (using the 8^th edition American Joint Committee on Cancer staging system), and survival outcomes. Statistical analyses utilized Kaplan-Meier estimates and Cox proportional hazards modeling, with adjustment for confounding variables.

RESULTS

Multivariate Cox proportional hazards analysis identified three independent predictors of survival: Tumor-node-metastasis staging [Hazard ratio (HR) = 2.31, 95% confidence interval (CI): 1.72-3.10, P < 0.001], tumor differentiation (moderate: HR = 1.46, 95%CI: 1.02-2.09, P = 0.038; poor: HR = 2.15, 95%CI: 1.47-3.14, P < 0.001), and extended postoperative analgesic use (> 5 days) (HR = 1.43, 95%CI: 1.08-1.89, P = 0.012). Kaplan-Meier analysis demonstrated significantly lower overall survival rates in patients requiring analgesics for > 5 days compared to ≤ 5 days (P = 0.003), with consistent patterns observed for both opioid (P = 0.019) and nonsteroidal anti-inflammatory drug use (P = 0.028). The extended analgesic group exhibited a higher proportion of elderly patients (48.47% vs 35.57%, P = 0.015), while other baseline characteristics and tumor features remained comparable between groups.

CONCLUSION

Tumor-node-metastasis staging, tumor differentiation, and duration of postoperative analgesic use independently predict survival following radical esophagectomy, underscoring the significance of optimal pain management protocols.

Quadratus lumborum block is feasible alternative to epidural block for postoperative analgesia after open radical cystectomy: surgical and oncological outcomes of a randomised clinical trial

OBJECTIVE

The current lack of standardised perioperative pain management protocols for open radical cystectomy (ORC) underscores the need for alternative approaches to the longstanding tradition of epidural block. The aim of this study was to assess the impact of bilateral single injection quadratum lumborum block (QLB) on patients' recovery and complication rates compared with epidural analgesia after ORC in a single-centre, randomised, parallel-group trial including adult patients with bladder cancer.

MATERIAL AND METHODS

Consecutive ORC patients were randomly allocated into QLB and the epidural group. The primary endpoint of this study was related to opioid consumption, and the results have been published earlier. This report focuses on secondary outcomes.

RESULTS

This study included a total of 41 patients, with 20 patients in the QLB group and 21 patients in the epidural group. Finally, 39 patients were included in the analysis.  There was a trend for more frequent need for postoperative norepinephrine and fluid support in the epidural group but without statistical significance. Postoperative complication rate was similar. Two patients in the epidural group compared to none in the QLB group were rehospitalised within 30 and 90 days. Mortality rate within 90 days was higher in the epidural group (4 vs. 0 patients, P = 0.064).

CONCLUSIONS

In this trial, there were no significant differences in surgical and oncological outcomes after ORC when QLB is compared with epidural block for postoperative analgesia.  Trial registration: ClinicalTrials.gov Identifier: NCT03328988.

Enhanced Recovery after Surgery - Evidence and Practice

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

Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament in patients undergoing laparoscopic radical gastrectomy: A randomised controlled study

OBJECTIVE

Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament has recently been proposed as an effective analgesia for abdominal surgery. To test the hypothesis that this novel technique was a viable alternative approach of conventional thoracic epidural analgesia for laparoscopic radical gastrectomy.

METHODS

Three hundred patients scheduled for laparoscopic radical gastrectomy were randomised 1:1 into the anterior quadratus lumborum block group: receiving the novel regional analgesia, and the thoracic epidural analgesia group: receiving thoracic epidural anaesthesia. The primary endpoint was intraoperative consumption of propofol and remifentanil. Intention-to-treat analysis was performed for all variables.

RESULTS

At five and ten minutes after block, anterior quadratus lumborum block group achieved more dermatomes coverage of the sensory block with both p < 0.001. Intraoperative consumption of propofol and remifentanil was comparable between two groups (1116.21 ± 199.76 versus 1166.45 ± 125.31µg, p = 0.245 and remifentanil 1.83 ± 0.41 versus 1.81 ± 0.37ng, p = 0.988). However, anterior quadratus lumborum block group was associated with less intraoperative consumption of norepinephrine and atropine, shorter time to urinary catheter removal and out-of-bed activity than the thoracic epidural anaesthesia group. No significant difference in extubation time, pain scores at rest and exercising at all time points following surgery was observed between the two groups.

CONCLUSIONS

Compared with conventional thoracic epidural anaesthesia, the novel technique was an equivalent effective component of multimodal analgesic protocol for laparoscopic radical gastrectomy. There were some advantages, including shorter procedure time, more reliable dermatomal coverage, shorter duration of urinary catheterisation and earlier time of out-of-bed activity to enhance recovery after surgery.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry on 2 November 2022 (ChiCTR2200065325).

Ask a Doctor a Question: A Clinician's Message to the Industry

The medical industry is an integral part of the delivery of healthcare. Collaboration between academic institutions, healthcare providers, and the industry are necessary but not devoid of flaws. This expert opinion article calls for closer attention to be paid by the medical industry to "what a frontline clinician needs" rather than relying solely on experts' opinions and stake holders' requests in planning future products and features. The need for the monitoring of tissue fluid accumulation is discussed from the point of view of practicing anaesthesiology and intensive care specialists in the context of the potential missed opportunity to have it be already available.

Simplified Enhanced Recovery After Surgery Intraoperative Fluid Management

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of restrictive versus liberal fluid therapy for laparoscopic gastric surgery on postoperative complications: a randomized controlled trial

PURPOSE

Currently, laparoscopic surgery is a standard technique in the field of abdominal surgery. However, the most adequate fluid regimen during laparoscopic surgery remains unclear. The aim of this trial is to compare a restricted fluid therapy with a liberal fluid therapy for laparoscopic abdominal surgery. Our hypothesis was that restrictive fluid therapy would reduce postoperative complications better than liberal fluid therapy.

METHOD

In this randomized controlled trial, patients scheduled for laparoscopic gastric surgery were randomized to either the liberal group (receiving 7-10 ml/kg/h of crystalloid) or the restrictive group (receiving 1-2 ml/kg/h of crystalloid) for each stratum of surgical procedure from April 2017 to March 2019. For both groups, blood loss was replaced by an equal volume of hydroxyethyl starch. The primary endpoint was postoperative complications up to 30 days after surgery, according to the Clavien-Dindo classification.

RESULTS

We enrolled 148 patients, and 140 of these were randomized to either the liberal or the restrictive group after exclusion. As a result, 69 cases were included in the liberal group for analysis, and 67 patients composed the restrictive group. Median fluid administration for the liberal and restrictive groups was 2950 ml and 800 ml, respectively. As well, overall complications in the liberal and restrictive groups were 27.5% and 19.4%, respectively (risk ratio 0.71, 95% confidence interval 0.38-1.31, p value = 0.264).

CONCLUSION

Restricted fluid therapy and liberal fluid therapy did not show any statistical differences in postoperative complications after laparoscopic gastric surgery.

A comprehensive operative risk assessment driving the application of major and emergency surgery in octogenarians

Medical decisions driving the clinical management of octogenarians who require either major or urgent surgery still depend on the patient's age rather than individual functions. This report created the privileged opportunity to illustrate the clinical effectiveness of a comprehensive function-based assessment. This was the case of an 83-year-old gentleman presenting with severe malnutrition and debility due to esophageal cancer. Multidimensional assessments were systematically performed to design the best-tailored therapeutic strategy, including prehabilitation, elective esophagectomy, and emergency laparotomy with ileocolic resection for postoperative hemorrhagic shock due to an occult colonic tumor. This clinical case highlights the need for a systematic and comprehensive assessment of fragile octogenarians, allowing accurate patient evaluation, identification of areas of functional optimization, and establishment of the most appropriate therapeutic decisions.

The Role of Patient-Controlled Epidural Analgesia in the Short-Term Outcomes of Laparoscopic-Assisted Gastrectomy in Elderly Gastric Cancer Patients

INTRODUCTION

Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) constitute two major advances in pain management after major abdominal surgery. However, the role of PCIA or PCEA has not been particularly studied in elderly patients with gastric cancer. The aim of this study is to make a comparison between PCIA and PCEA in terms of their performance on short-term outcomes in elderly patients undergoing laparoscopic-assisted gastrectomy.

METHODS

This single-center, retrospective study included 254 elderly patients (≥70 y) who underwent laparoscopic radical gastrectomy for gastric cancer. Patients received either general anesthesia combined with epidural anesthesia followed by PCEA (PCEA group, n = 123) or general anesthesia alone followed by PCIA (PCIA group, n = 131). The primary endpoint was pain intensity-tested using a 100-mm visual analog scale on postoperative days 1, 2, and 3. Demographics, comorbidities, perioperative data, postoperative short-term outcomes, and analgesia-related side effects were also assessed.

RESULTS

The visual analog scale scores at rest were lower in the PCEA group compared to the PCIA group on postoperative day 1, 2, and 3 (27.8 ± 13.9 versus 33.1 ± 15.0, P = 0.004; 25.2 ± 11.3 versus 30.1 ± 14.3, P = 0.002; 16.9 ± 7.1 versus 20.9 ± 9.5, P < 0.001, respectively). The postoperative hospital stay was shorter in the PCEA group than in the PCIA group (11 versus 12 d, P = 0.018). The times to postoperative first flatus, semifluid diet, independent ambulation, and tracheal extubation after surgery in the PCEA group were significantly shorter than in the PCIA group. Overall morbidity, mortality, hospital readmission rate, and reoperation rate were not significantly different between the two groups. Regarding side-effects related to analgesia, there were no significant differences in terms of the rates of postoperative nausea and vomiting, urinary retention, or oxygen saturation <90% between the two groups. However, PCEA was associated with a higher incidence of postoperative hypotension compared to PCIA (10.6% versus 3.8%, P = 0.036).

CONCLUSIONS

In elderly patients undergoing laparoscopic radical gastrectomy, epidural anesthesia and analgesia may convey superior pain relief, faster restoration of gastrointestinal motility, and shorter hospitalization.

Association between intraoperative fluid management and postoperative outcomes in living kidney donors: a retrospective cohort study

Optimal fluid strategy for laparoscopic donor nephrectomy (LDN) remains unclear. LDN has been a domain for liberal fluid management to ensure graft perfusion, but this can result in adverse outcomes due to fluid overload. We compared postoperative outcome of living kidney donors according to the intraoperative fluid management. Five hundred and five LDNs performed over a six-year period at a tertiary hospital were analyzed. Donors were divided into tertiles according to intraoperative crystalloid infusion rate (ml/kg/hr), and associations between the tertile and outcomes were investigated with inverse probability of treatment weighting with entropy balancing. Primary outcome was maximal rise of serum creatinine (sCr). Secondary outcomes were sCr rise meeting Acute Kidney Injury (AKI) criteria, time to reach minimal sCr, and length of hospital stay. The following covariates were used: age, sex, body weight, height, diabetes mellitus, hypertension, preoperative estimated glomerular filtration rate, operation duration, surgeon, nephrectomy side, and estimated blood loss. Median intraoperative crystalloid infusion rate was 3.5, 4.6, and 6.0 ml/kg/hr in the first, second, and third tertile, respectively (group 1, 2, and 3). Maximal rise of sCr did not differ between groups (P = 0.274). Twofold increase in sCr (equivalent to stage 2 AKI) during the first week and prolonged hospitalization were most frequent in group 1 [7.8 vs. 1.1 vs. 1.5%, P = 0.004; 7.9 vs. 3.1 vs. 0.7%, P = 0.003]. Time to reach minimal sCr was longest in group 1. No differences were found in recipient early renal function. Hypovolemia is associated with poor postoperative outcomes after LDN. Efforts to find the optimal fluid management should be continued.

Immunocyte profiling changes in patients received epidural versus intravenous analgesia after pancreatectomy: A randomized controlled trial

BACKGROUND

Perioperative immunosuppressants, such as surgical stress and opioid use may downregulate anti-cancer immunocytes for patients undergoing pancreatectomy. Thoracic epidural analgesia (TEA) may attenuate these negative effects and provide better anti-cancer immunocyte profile change than intravenous analgesia using opioid.

METHODS

We randomly assigned 108 adult patients undergoing pancreatectomy to receive one of two 72-h postoperative analgesia protocols: one was TEA, and the other was intravenous patient-controlled analgesia (IV-PCA). The perioperative proportional changes of immunocytes relevant to anticancer immunity-namely natural killer (NK) cells, cytotoxic T cells, helper T cells, mature dendritic cells, and regulatory T (Treg) cells were determined at 1 day before surgery, at the end of surgery and on postoperative day 1,4 and 7 using flow cytometry. In addition, the progression-free survival and overall survival between the two groups were compared.

RESULTS

After surgery, the proportions of NK cells and cytotoxic T cells were significantly decreased; the proportion of B cells and mature dendritic cells and Treg cells were significantly increased. However, the proportions of helper T cells exhibited no significant change. These results were comparable between the two groups. Furthermore, there were no significant differences in progression-free survival (52.75 [39.96] and 57.48 [43.66] months for patients in the TEA and IV-PCA groups, respectively; p = 0.5600) and overall survival (62.71 [35.48] and 75.11 [33.10] months for patients in the TEA and IV-PCA groups, respectively; p = 0.0644).

CONCLUSION

TEA was neither associated with favorable anticancer immunity nor favorable oncological outcomes for patients undergoing pancreatectomy.

Enhancing Recovery in Gastrointestinal and Cardiovascular Surgeries Through Enhanced Recovery After Surgery (ERAS) Protocols

Enhanced Recovery After Surgery (ERAS) protocols aim to improve perioperative outcomes and expedite recovery across various surgical specialties. While ERAS protocols have shown significant benefits in gastrointestinal and cardiovascular surgeries, their impact and effectiveness require further synthesis. This systematic review and meta-analysis evaluated the efficacy of ERAS protocols in enhancing recovery and reducing complications in gastrointestinal and cardiovascular surgeries. High-quality studies were selected based on adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and quality assessment using the Newcastle-Ottawa Scale (NOS). A systematic review and meta-analysis of six high-quality studies involving 45,678 patients were conducted using databases such as PubMed, MEDLINE, EMBASE, and Cochrane Central. Data on length of hospital stay (LOS), complications, 30-day readmissions, and mortality were extracted. Statistical analysis employed random-effects models to calculate pooled effect sizes, odds ratios (ORs), and hazard ratios. Subgroup analyses were performed based on surgery type, patient age, comorbidities, and follow-up duration. ORs for postoperative complications varied across subgroups (e.g., urgent vs. elective surgeries), with some ranges (e.g., 0.65-1.02) reflecting mixed effects; sensitivity analyses confirmed the robustness of pooled outcomes. Recovery times ranged from 1 to 3 days for gastrointestinal surgeries and 4 to 9 days for cardiovascular surgeries, demonstrating clinically meaningful variability. ERAS protocols showed greater recovery benefits in urgent surgeries (HR = 1.42, 95% CI: 1.15-1.75) and in patients with comorbidities (HR = 1.62, 95% CI: 1.33-1.96), likely due to their emphasis on rapid stabilization of perioperative care, including early mobilization and nutritional support. Heterogeneity, assessed through sensitivity analyses, ranged from moderate to substantial across subgroup analyses. ERAS protocols consistently enhance recovery outcomes, minimize complications, and reduce hospital stays in gastrointestinal and cardiovascular surgeries, demonstrating their utility in optimizing perioperative care. Future research should explore long-term outcomes and tailored implementation strategies to address patient-specific needs.

Vastus lateralis nerve block for knee hardware removal

Effective pain management post-knee surgery is critical for recovery and minimizing opioid use. We present a case of a patient undergoing ORIF for a comminuted patellar fracture and subsequent hardware removal because of persistent medial knee pain from hardware prominence. Despite initial opioid administration under general anesthesia, severe postoperative pain necessitated rescue with peripheral nerve blocks. Adductor canal, anterior femoral cutaneous, and vastus lateralis blocks provided significant pain relief without additional opioids. This approach reduces systemic opioid exposure, crucial in the current opioid crisis. Peripheral nerve blocks, especially the vastus lateralis block, effectively managed severe postoperative pain, highlighting their role in opioid-sparing strategies. These findings advocate for the broader adoption of regional anesthesia to enhance perioperative outcomes amid opioid-related challenges while supporting early mobilization and rehabilitation.

Environmental impact of the enhanced recovery pathway in colorectal surgery: A simulation study

AIM

Most of the literature on the environmental impact of surgery has analysed operating theatre practice in terms of its contribution to global warming (by greenhouse gas effects). The aim of this study was to assess the overall environmental impact of a complete perioperative pathway with and without implementation of an enhanced recovery programme (ERP).

METHOD

We compared two scenarios: an ERP scenario and a conventional scenario (CONV) for colorectal surgery. We carried out a lifecycle analysis for perioperative procedures, devices and consumables. We measured the impact on 17 environmental variables in addition to global warming.

RESULTS

The overall environmental impact of ERP was 6% lower than that of conventional care. The reduction of impact due to ERP ranged from 5% for greenhouse gas emissions (18 kg CO2 equivalent less per intervention) to 27% for water consumption (3 m3 less). The stages that had the most impact on the environment were the preoperative stage (essentially owing to patient travel) and the intraoperative stage with the surgical part (medical devices representing 83.3% of the impact of the procedure) and the anaesthesia part (halogenated gases and ventilation representing 54.9% of the impact of anaesthesia care).

CONCLUSION

This study found an ERP approach to be more eco-responsible than conventional care. This is an additional benefit of ERP implementation. The impact of ERP implementation might be further reduced by action on the preoperative and intraoperative stages.

PONV Management in Adult Patients: Evidence-based Summary

PURPOSE

To summarize the evidence on perioperative nausea and vomiting management in adult patients worldwide.

DESIGN

This is a summary of the best evidence on postoperative nausea and vomiting in adults.

METHODS

Databases such as British Medical Journal Best Practice, Cochrane Library, Joanna Briggs Institute, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, National Guideline Clearing House, Guidelines International Network, American Society of Anesthesiologists (ASA), Association of periOperative Registered Nurses (AORN), Registered Nurses Association of Ontario, PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Yimaitong Clinical Guidelines, China Anesthesia Official website, SinoMed, China National Knowledge Infrastructure, Wanfang, and VIP were searched to collect the relevant guidelines for clinical decision-making, best practices, systematic review, evidence summary, and expert consensus about perioperative nausea and vomiting management. The retrieval time was from the establishment of the database to January 2022. Two authors independently evaluated the quality of the included literature and extracted and summarized the evidence that met the quality criteria.

FINDINGS

A total of 22 studies, including 1 best practice, 2 clinical decision-making articles, 7 evidence summaries, 1 clinical guideline, 9 systematic reviews, and 2 expert consensuses, were included. The summary of 37 pieces of evidence from 7 aspects: risk factors, assessment methods, multimodal prevention strategy, health education, nondrug intervention, drug prevention, postoperative analgesia management strategy, and organization management.

CONCLUSIONS

The health care team should select the best evidence according to the characteristics of the department and clinical practice, scientifically manage perioperative nausea and vomiting of patients, reduce the incidence and severity of nausea and vomiting, and promote the accelerated rehabilitation of patients.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery

BACKGROUND

Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery.

PATIENTS AND METHODS

A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications.

RESULTS

Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3-G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3-G5) in the case of a PFE ≥ 3000 ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000 ml (p = 0.006).

CONCLUSIONS

Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000 ml and ≥ 4000 ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

Fluid management in the septic peri-operative patient

PURPOSE OF REVIEW

This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications.

RECENT FINDINGS

Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content).

SUMMARY

Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

A review of enhanced recovery after surgery concept in perioperative radical prostatectomy for prostate cancer

Radical prostatectomy (RP) is the main treatment for early-stage localized prostate cancer. With the improvement of medical technology, radical prostatectomy is mainly performed under laparoscopy or robot assistance. With the continuous deepening of the Enhanced Recovery After Surgery (ERAS) concept in clinical practice, patients have increasingly high requirements for postoperative recovery. The ERAS concept is of great significance in the perioperative period and has been used in many surgical fields due to its ability to improve prognosis. ERAS has not yet been widely applied in urology and the research progress of other disciplines in ERAS has promoted its development in radical prostatectomy. This review summarizes the key elements of ERAS in the perioperative period of RP, aiming to demonstrate the superiority of ERAS and provide new references and inspirations for urologists.

The effects of rapid rehabilitation nursing on improving postoperative rehabilitation effect and life quality of early breast cancer patients

This study was intended to determine whether rapid rehabilitation nursing can enhance postoperative rehabilitation and life quality for breast cancer (BC) patients. One hundred seventy-two patients with BC treated in our hospital from March 2020 to September 2022 were included in this retrospective study and divided into the observation group (n = 86) and control group (n = 86) based on the different nursing methods that they received. The control group accepted routine nursing care, and the observation group accepted rapid rehabilitation nursing intervention. The amount of intraoperative blood loss, anesthesia awake time, postoperative drainage tube removal time, postoperative time of getting out of bed, length of hospital stays, incidence of postoperative complications, and postoperative recovery rate of affected limb, Barthel index and quality of life instruments for cancer patients: breast cancer (QLICP-BR) of BC patients were analyzed. The amount of intraoperative bleeding in the observation group was less, and the difference was statistically significant (P < .05). The awake time of anesthesia, the time of pulling out the drainage tube after operation, the time of getting out of bed after operation and the time of hospitalization in the observation group were significant shorter (P < .05). The incidence of postoperative complications in the observation group was notably lower (P < .05). The excellent and good rate of postoperative rehabilitation of the affected limbs in the observation group was notably higher (P < .05). Before nursing, there exhibited no notable difference in the scores of Barthel index (P > .05). After 10 days of nursing, the score of Barthel index in the observation group was notably higher (P < .05). After 10 days of nursing, the QLICP-BR score of the observation group was significant higher (P < .05). Rapid rehabilitation nursing is beneficial to reduce the intraoperative blood loss of BC patients, shorten the recovery time of anesthesia, promote the excellent and good rate of rehabilitation of affected limbs, and improve the quality of life.

Generation of preoperative anaesthetic plans by ChatGPT-4.0: a mixed-method study

BACKGROUND

Recent advances in artificial intelligence (AI) have enabled development of natural language algorithms capable of generating coherent texts. We evaluated the quality, validity, and safety of this generative AI in preoperative anaesthetic planning.

METHODS

In this exploratory, single-centre, convergent mixed-method study, 10 clinical vignettes were randomly selected, and ChatGPT (OpenAI, 4.0) was prompted to create anaesthetic plans, including cardiopulmonary risk assessment, intraoperative anaesthesia technique, and postoperative management. A quantitative assessment compared these plans with those made by eight senior anaesthesia consultants. A qualitative assessment was performed by an adjudication committee through focus group discussion and thematic analysis. Agreement on cardiopulmonary risk assessment was calculated using weighted Kappa, with descriptive data representation for other outcomes.

RESULTS

ChatGPT anaesthetic plans showed variable agreement with consultants' plans. ChatGPT, the survey panel, and adjudication committee frequently disagreed on cardiopulmonary risk estimation. The ChatGPT answers were repetitive and lacked variety, evidenced by the strong preference for general anaesthesia and absence of locoregional techniques. It also showed inconsistent choices regarding airway management, postoperative analgesia, and medication use. While some differences were not deemed clinically significant, subpar postoperative pain management advice and failure to recommend tracheal intubation for patients at high risk for pulmonary aspiration were considered inappropriate recommendations.

CONCLUSIONS

Preoperative anaesthetic plans generated by ChatGPT did not consistently meet minimum clinical standards and were unlikely the result of clinical reasoning. Therefore, ChatGPT is currently not recommended for preoperative planning. Future large language models trained on anaesthesia-specific datasets might improve performance but should undergo vigorous evaluation before use in clinical practice.

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine.

Enhanced recovery after fetal spina bifida surgery: global practice

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients.

METHODS

In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20.

RESULTS

The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume.

CONCLUSIONS

The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.

The effect of virtual reality hypnosis (HypnoVR) in patients undergoing inguinal hernia repair under local anesthesia. A preliminary report

INTRODUCTION

Surgical procedures, even under local anesthesia, can induce significant stress and anxiety in patients. Innovative approaches to alleviate anxiety are crucial for improving patient outcomes. Sedatives and anxiolytics may alleviate this discomfort, but they can also subject patients to undesirable side effects, diminishing their overall effectiveness, and, finally, delaying discharge. We present the first case series of a patients underwent inguinal hernia surgical repair under local anesthesia using VRH (HypnoVR) to avoid use of sedatives and anxiolytics.

METHODS

12 consecutive patients were enrolled to undergo elective monolateral inguinal hernia repair surgery via an open approach using HypnoVR, at Colorectal Surgery Unit of Fondazione Policlinico Universitario Campus Bio-Medico di Roma. Vital signs (heart rate, SpO2, blood pressure) were detected for all patients before surgery, during local anesthesia, during the whole intervention and after surgery.

RESULTS

No intraoperative or postoperative complications have been recorded and only one postoperative complication occurred (seroma), which not required invasive treatment but only drug administration. All patient's vital parameters were recorded during all operative and perioperative phasis. No use of intraoperative analgesic, sedative or anxiolytic were needed. All patients were discharged no later than 3 h after surgery.

CONCLUSION

Virtual Reality Hypnosis is a promising tool for anxiety management in surgical settings. Our series highlights the positive impact of HypnoVR in reduction and management of surgical patient anxiety and discomfort, allowing to perform inguinal hernia repair using only local anesthesia, with good patients' satisfaction.

Post-Anesthesia Recovery: A Comprehensive Review of Sampe, Modified Aldrete, and White Scoring Systems

Post-anesthesia recovery is a vital phase in the perioperative continuum, where the quality of care and monitoring heavily influence patient outcomes. This comprehensive review examines the Sampe, Modified Aldrete, and White Scoring Systems, pivotal in evaluating patients' readiness for discharge from the Post-Anesthesia Care Unit (PACU). The review delves into the historical evolution of post-anesthesia care, highlighting the transition from minimal post-operative support to the establishment of PACUs and the subsequent development of structured recovery scoring systems. Each scoring system is analyzed in detail, focusing on its components, criteria, scoring methodology, advantages, and limitations. A comparative analysis underscores these systems' similarities and differences, sensitivity, specificity, and practical applications in clinical settings. Additionally, the review discusses the clinical implications of these scoring systems in enhancing patient management, improving safety, and ensuring standardized care. Emerging technologies and future directions in recovery assessment are also explored, providing insights into potential innovations. This review aims to equip healthcare professionals with a deeper understanding of these scoring systems, facilitating informed decisions to optimize post-anesthesia care and patient outcomes.

Comparison of Gastric Residual Volume After Ingestion of A Carbohydrate Drink and Water in Healthy Volunteers with Obesity: A Randomized Crossover Study

INTRODUCTION

Preoperative carbohydrate intake is essential to enhance postoperative recovery. However, its safety for individuals with obesity remains unclear. This study investigated the safety of preoperative carbohydrate consumption compared to water intake in obese populations through gastric volume assessment.

METHODS

A prospective randomized crossover study enrolled 30 healthy volunteers aged 18-65 years with a body mass index ≥ 30 kg/m2, following a minimum 6-h fast. The participants received either 400 ml of a carbohydrate drink (group C) or water (group W). Gastric ultrasonography, blood glucose level, hunger, and thirst assessments were conducted at baseline (T) and various time points (T2 to T6). The protocol was repeated with reverse interventions at least 1 week later.

RESULTS

Group C had significantly higher gastric volume at T3, T4, and T5 compared to group W, with a prolonged time to empty the gastric antrum (94.4 ± 28.5 vs. 61.0 ± 33.5 min, 95% CI 33.41 [17.06,24.69]). However, glucose levels, degrees of hunger, and thirst showed no significant differences between the groups.

CONCLUSION

Administering 400 ml of preoperative carbohydrates to healthy obese individuals 2 h preoperatively is safe and comparable to water intake. These findings support the integration of carbohydrate loading into perioperative care for obese individuals, consistent with the enhanced recovery after surgery protocols. Further research is warranted to refine preoperative fasting protocols and improve surgical outcomes in this population.

Applying enhanced recovery principles to emergency laparotomy in penetrating abdominal trauma: a case-matched study

PURPOSE

The implementation of enhanced recovery after surgery programs (ERPs) has significantly improved outcomes within various surgical specialties. However, the suitability of ERPs in trauma surgery remains unclear. This study aimed to (1) design and implement an ERP for trauma laparotomy patients; (2) assess its safety, feasibility, and efficacy; and (3) compare the outcomes of the proposed ERP with conventional practices.

METHODS

This case-matched study prospectively enrolled hemodynamically stable patients undergoing emergency laparotomy after penetrating trauma. Patients receiving the proposed ERP were compared to historical controls who had received conventional treatment from two to eight years prior to protocol implementation. Cases were matched for age, sex, injury mechanism, extra-abdominal injuries, and trauma scores. Assessment of intervention effects were modelled using regression analysis for outcome measures, including length of hospital stay (LOS), postoperative complications, and functional recovery parameters.

RESULTS

Thirty-six consecutive patients were enrolled in the proposed ERP and matched to their 36 historical counterparts, totaling 72 participants. A statistically significant decrease in LOS, representing a 39% improvement in average LOS was observed. There was no difference in the incidence of postoperative complications. Opioid consumption was considerably lower in the ERP group (p < 0.010). Time to resumption of oral liquid and solid intake, as well as to the removal of nasogastric tubes, urinary catheters, and abdominal drains was significantly earlier among ERP patients (p < 0.001).

CONCLUSION

The implementation of a standardized ERP for the perioperative care of penetrating abdominal trauma patients yielded a significant reduction in LOS without increasing postoperative complications. These findings demonstrate that ERPs principles can be safely applied to selected trauma patients.

A Retrospective Comparison Trial Investigating Aggregate Length of Stay Post Implementation of Seven Enhanced Recovery After Surgery (ERAS) Protocols between 2015 and 2022

(1) Introduction: Enhanced Recovery After Surgery (ERAS) protocols can create a cultural shift that will benefit patients by significantly reducing patient length of stay when compared to an equivalent group of surgical patients not following an ERAS protocol. (2) Methods: In this retrospective study of 2236 patients in a multi-center, community-based healthcare system, matching was performed based on a multitude of variables related to demographics, comorbidities, and surgical outcomes across seven ERAS protocols. These cohorts were then compared pre and post ERAS protocol implementation. (3) Results: ERAS protocols significantly reduced hospital length of stay from 3.0 days to 2.1 days (p <0.0001). Additional significant outcomes included reductions in opioid consumption from 40 morphine milligram equivalents (MMEs) to 20 MMEs (p <0.001) and decreased pain scores on postoperative day zero (POD 0), postoperative day one (POD 1), and postoperative day two (POD 2) when stratified into mild, moderate, and severe pain (p <0.001 on all three days). (4) Conclusions: ERAS protocols aggregately reduce hospital length of stay, pain scores, and opioid consumption.

Analysis of contributing factors and nursing interventions for postoperative agitation following general anesthesia in thoracotomy patients

To analyze the factors influencing agitation during emergence from general anesthesia in patients undergoing thoracotomy and to explore corresponding nursing interventions to optimize the postoperative recovery process. This study included 200 patients who underwent thoracotomy with general anesthesia at our hospital between January 12, 2022, and June 1, 2023. After surgery, all patients were closely monitored in the Intensive Care Unit (ICU). Based on their agitation status during emergence from anesthesia, patients were divided into 2 groups: an observation group (87 cases with agitation) and a control group (113 cases without agitation). We performed univariate analysis and multivariate logistic regression to identify risk factors for agitation. Based on these findings, we proposed targeted nursing strategies to address the causes of agitation, prevent complications, and meet patient care needs. Univariate analysis showed significant differences between the observation and control groups regarding age, propofol dosage, duration of surgery, infusion volume, and preoperative cognitive dysfunction (P < .05). Multivariate logistic regression identified 3 key risk factors: age over 60 years, surgery duration over 2 hours, and preoperative cognitive dysfunction. Based on these findings, we developed targeted nursing strategies to reduce the incidence of agitation and promote smooth recovery. Agitation during emergence from general anesthesia in patients undergoing thoracotomy is closely related to factors such as age and surgery duration. Developing personalized nursing plans based on these factors can enhance postoperative monitoring and care, thereby reducing agitation and improving recovery quality.

Impact of perioperative fluid overload on the occurrence of postoperative pulmonary complications following lobectomy

Background

The incidence of pulmonary complications following lobectomy remains substantial, with postoperative fluid volume playing a pivotal role. However, the optimal management of fluids after lobectomy remains uncertain. This study aimed to establish a benchmark for perioperative fluid overload in patients undergoing pulmonary surgery by comparing the incidence of pulmonary complications following standard surgical procedures among patients with varying fluid volumes.

Methods

A retrospective analysis was conducted on adult patients with non-small cell lung cancer (NSCLC) who underwent lobectomy between January 2018 and January 2019. The primary exposure variable was fluid overload within the initial 24-hour period. The observation outcomes were postoperative pulmonary complications, acute kidney injury (AKI), and postoperative length of stay. Univariate and multivariate analyses were performed.

Results

Among the 300 patients included in this study, the low-volume group exhibited a significantly shorter postoperative hospital stay compared to the high-volume group (P=0.02). Furthermore, the low-volume group demonstrated a significantly lower incidence of postoperative atelectasis (P=0.03) and pulmonary infection (P=0.02) compared to the high-volume group. Moreover, logistic regression analysis revealed that the high-volume group had higher odds ratios (ORs) for developing atelectasis [OR: 2.611, 95% confidence interval (CI): 1.050-6.496, P=0.04] and pulmonary infection (OR: 2.642, 95% CI: 1.053-6.630, P=0.04) following lobectomy when compared to the low-volume group.

Conclusions

In patients with NSCLC undergoing lobectomy, reducing intravenous infusion after surgery while maintaining hemodynamic stability can effectively shorten hospitalization duration and mitigate the risk of postoperative atelectasis and pulmonary infection.

Emergency Awake Laparotomy Using Neuraxial Anaesthesia: A Case Series and Literature Review

Emergency laparotomy is a surgical procedure associated with significantly higher mortality rates compared to elective surgeries. Awake laparotomy under neuraxial anaesthesia has recently emerged as a promising approach in abdominal surgery to improve patient outcomes. This study aims to evaluate the feasibility and potential benefits of using neuraxial anaesthesia as the primary anaesthetic technique in emergency laparotomies. We conducted a case series involving 16 patients who underwent emergency laparotomy for bowel ischemia, perforation, or occlusion. Neuraxial anaesthesia was employed as the main anaesthetic technique. We analysed patient demographics, clinical characteristics, intraoperative details, and postoperative outcomes. The primary outcome measures included the adequacy of postoperative pain control, the incidence of postoperative complications, and mortality rates. Among the 16 patients, adequate postoperative pain control was achieved, with only 2 patients requiring additional analgesia. Postoperative complications, including sepsis, wound dehiscence, and pneumonia, were observed in seven patients (44%). The observed mortality rate was relatively low at 6% (one patient). Notably, conversion to general anaesthesia was not necessary in any of the cases, and no early readmissions were reported. Our findings highlight the feasibility and potential benefits of using neuraxial anaesthesia in emergency laparotomies. The observed low mortality rate and the avoidance of conversion to general anaesthesia suggest that neuraxial anaesthesia may be a useful alternative in emergency settings. However, the occurrence of postoperative complications in 44% of patients indicates the need for cautious patient selection and close monitoring. Further research with larger sample sizes is warranted to fully elucidate the efficacy, safety, and potential impact of this technique on patient outcomes in emergency laparotomies.

Effectiveness Assessment of Bispectral Index Monitoring Compared with Conventional Monitoring in General Anesthesia: A Systematic Review and Meta-Analysis

Background and Objective. The Bispectral Index (BIS) is utilized to guide the depth of anesthesia monitoring during surgical procedures. However, conflicting results regarding the benefits of BIS for depth of anesthesia monitoring have been reported in numerous studies. The purpose of this meta-analysis and systematic review was to assess the effectiveness of BIS for depth of anesthesia monitoring. Search Methods. A systematic search of Ovid-MEDLINE, Cochrane, and PubMed was conducted from inception to April 20, 2023. Clinical trial registers and grey literature were also searched, and reference lists of included studies, as well as related review articles, were manually reviewed. Selection Criteria. The inclusion criteria were randomized controlled trials without gender or age restrictions. The control groups used conventional monitoring, while the intervention groups utilized BIS monitoring. The exclusion criteria included duplicates, reviews, animal studies, unclear outcomes, and incomplete data. Data Collection and Analysis. Two independent reviewers screened the literature, extracted data, and assessed methodological quality, with analyses conducted using R 4.0 software. Main Results. Forty studies were included. In comparison to the conventional depth of anesthesia monitoring, BIS monitoring reduced the postoperative cognitive dysfunction risk (RR = 0.85, 95% CI: 0.73∼0.99, P = 0.04), shortened the eye-opening time (MD = -1.34, 95% CI: -2.06∼-0.61, P < 0.01), orientation recovery time (MD = -1.99, 95% CI: -3.62∼-0.36, P = 0.02), extubation time (MD = -2.54, 95% CI: -3.50∼-1.58, P < 0.01), and postanesthesia care unit stay time (MD = -7.11, 95% CI: -12.67∼-1.55, P = 0.01) and lowered the anesthesia drug dosage (SMD = -0.39, 95% CI: -0.63∼-0.15, P < 0.01). Conclusion. BIS can be used to effectively monitor the depth of anesthesia. Its use in general anesthesia enhances the effectiveness of both patient care and surgical procedures.

The incidences of nausea and vomiting after general anesthesia with remimazolam versus sevoflurane: a prospective randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) refers to nausea and vomiting that occurs within 24-h after surgery or in the post-anesthesia care unit (PACU). Previous studies have reported that the use of remimazolam, a newer benzodiazepine (BDZ) hypnotic, for anesthesia results in less PONV. In this study, we compared the rate of PONV between sevoflurane and remimazolam after general anesthesia.

METHODS

In this prospective randomized controlled trial, participants aged 20-80 years who underwent elective laparoscopic cholecystectomy or hemicolectomy were randomized to either the remimazolam or sevoflurane group. The primary outcome was PONV incidence for 24-h after surgery. Secondary outcomes comprised of PONV at 30-min post-surgery, postoperative additional antiemetic use, and Quality of Recovery-15 (QOR-15) score at 24-h postoperatively.

RESULTS

Forty patients were enrolled in the study. The remimazolam group exhibited significantly lower rates of PONV for 24-h after surgery than did the sevoflurane group (remimazolam group vs. sevoflurane group; 5% vs. 45%, P = 0.003, respectively). The use of dexamethasone, a rescue antiemetic administered within 24 h of surgery, was substantially lower in the remimazolam group than in the sevoflurane group (0% in remimazolam vs. 30% in sevoflurane, P = 0.020). The QOR-15 score at 24-h after surgery showed no significant difference between the two groups.

CONCLUSIONS

Compared to sevoflurane, opting for remimazolam as an intraoperative hypnotic may decrease the incidence of PONV and reduce antiemetic use for 24 h after laparoscopic surgery.

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

Safety and feasibility of early drinking water after general anesthesia recovery in patients undergoing daytime surgery

BACKGROUND

Patients who are recovering from general anesthesia commonly exhibit symptoms such as dry lips, throat irritation, and thirst, prompting a desire to drink water in the post-anesthesia care unit (PACU). In this study, we aimed to evaluate the therapeutic effects and any potential complications of administering varying quantities of water to such patients. The primary objectives are to assess the safety and feasibility of early water intake after general anesthesia, specifically in the context of daytime surgery.

METHODS

A total of 200 nongastrointestinal patients who underwent outpatient surgery were randomly assigned to four groups: Group A (drinking < 1 ml/kg), Group B (drinking 1-2 ml/kg), Group C (drinking > 2 ml/kg), and Group D (no water intake). We monitored changes in the assessment parameters before and after water consumption, as well as the incidence of post-drinking nausea and vomiting, and compared these outcomes among the four groups.

RESULTS

Water intake led to a significant reduction in thirst, oropharyngeal discomfort, and pain scores and a notable increase in the gastric antrum motility index (MI), exhibiting statistical significance compared to the values before drinking (p < 0.05). Remarkably, higher water consumption correlated with enhanced gastrointestinal peristalsis. There was a significant difference in the antral MI among groups B, C, and A (p < 0.05). The occurrence of nausea and vomiting did not significantly differ among groups A, B, C, and D (p > 0.05). Early water consumption enhanced patient satisfaction with medical care, significantly varying from Group D (p < 0.05).

CONCLUSION

Non-gastrointestinal surgical patients who passed pre-drinking water assessments post GA(general anesthesia)recovery could safely ingest moderate amounts of water in the PACU. Early water intake is both safe and feasible, effectively fostering swift postoperative recovery.

Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach

INTRODUCTION

The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach.

PATIENTS AND METHODS

All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed.

RESULTS

The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group.

CONCLUSION

Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study

BACKGROUND

Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU).

METHODS

We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics.

RESULTS

Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 μg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56).

CONCLUSIONS

The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.

Management of Major Complications After Esophagectomy

Esophagectomy remains a procedure with one of the highest complication rates. Given the advances in medical and surgical management of patients and increased patient survival, the number of complications reported has increased. There are different grading systems for complications which vary based on severity or organ system, with the Esophageal Complications Consensus Group unifying them. Management involves conservative intervention and dietary modification to endoscopic interventions and surgical reintervention. Treatment is etiology specific but rehabilitation and patient optimization play a significant role in managing these complications by preventing them. Management is a step-up approach depending on the severity of symptoms.

The effect of restrictive compared to liberal intravenous fluid volume on hypotension in adults undergoing major abdominal surgery

In a cardiac output (CO) sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial, it was shown that restrictive fluid management was associated with lower cardiac index at the end of surgery. However, the association of the fluid protocol with intraoperative blood pressure was less clear. This paper primarily compares rates of hypotension between the two fluid regimens. The haemodynamic effects of these protocols may increase our understanding of perioperative fluid prescription. Using a data set of arterial pressure and cardiac output measurements, this observational cohort study primarily compares intraoperative hypotension rates defined by a mean arterial pressure < 65 mmHg between liberal and restrictive fluid protocols. Secondary analyses explore predictors of invasive mean arterial pressure and doppler-derived cardiac output, including fluid volume regimens and surgical duration. 105 patients had a combined total of 835 haemodynamic data capture events from the beginning to the end of the surgery. Here we report that a restrictive regimen is not associated with a greater proportion of participants who experience at least one episode of hypotension than the liberal regimen 64.1% vs. 61.5% (mean difference 2.6%, 95% CI - 15.9% to 21%, p = 0.78). Duration of surgery was associated with an increased risk of hypotension (OR 1.05, 1 to 1.1, p = 0.038). A fluid restriction protocol compared to liberal fluid administration is not associated with lower blood pressure.

ERAS for Ambulatory TURBT: Enhancing Bladder Cancer Care (EMBRACE) randomised controlled trial protocol

INTRODUCTION

Transurethral resection of bladder tumour (TURBT) is one of the more common procedures performed by urologists. It is often described as an 'incision-free' and 'well-tolerated' operation. However, many patients experience distress and discomfort with the procedure. Substantial opportunity exists to improve the TURBT experience. An enhanced recovery after surgery (ERAS) protocol designed by patients with bladder cancer and their providers has been developed.

METHODS AND ANALYSIS

This is a single-centre, randomised controlled trial to investigate the effectiveness of an ERAS protocol compared with usual care in patients with bladder cancer undergoing ambulatory TURBT. The ERAS protocol is composed of preoperative, intraoperative and postoperative components designed to optimise each phase of perioperative care. 100 patients with suspected or known bladder cancer aged ≥18 years undergoing initial or repeat ambulatory TURBT will be enrolled. The change in Quality of Recovery 15 score, a measure of the quality of recovery, between the day of surgery and postoperative day 1 will be compared between the ERAS and control groups.

ETHICS AND DISSEMINATION

The trial has been approved by the Johns Hopkins Institutional Review Board #00392063. Participants will provide informed consent to participate before taking part in the study. Results will be reported in a separate publication.

TRIAL REGISTRATION NUMBER

NCT05905276.

Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives

In the early days of anaesthesia, the fasting period for liquids was kept short. By the mid-20th century 'nil by mouth after midnight' had become routine as the principles of the management of 'full stomach' emergencies were extended to include elective healthy patients. Back then, no distinction was made between the withholding of liquids and solids. Towards the end of the last century, recommendations of professional anaesthesiology bodies began to reduce the fasting time of clear liquids to 2 h. This reduction in fasting time was based on the understanding that gastric emptying of clear liquids is rapid, exponential, and proportional to the current filling state of the stomach. Furthermore, there was no evidence of a link between drinking clear liquids and the risk of aspiration. Indeed, most instances of aspiration are caused by failure to identify aspiration risk factors and adjust the anaesthetic technique accordingly. In contrast, long periods of liquid withdrawal cause discomfort and may also lead to serious postoperative complications. Despite this, more than two decades after the introduction of the 2 h limit, patients still fast for a median of up to 12 h before anaesthesia, mainly because of organisational issues. Therefore, some hospitals have decided to allow patients to drink clear liquids within 2 h of induction of anaesthesia. Well-designed clinical trials should investigate whether these concepts are safe in patients scheduled for anaesthesia or procedural sedation, focusing on both aspiration risk and complications of prolonged fasting.

Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

Association of preoperative thyroid hormone replacement with perioperative complications after major abdominal surgery

OBJECTIVE

To determine the association between preoperative thyroid hormone replacement and complications following major abdominal surgery.

METHODS

A retrospective case series was performed of patients enrolled in the Michigan Surgical Quality Collaborative (MSQC) who underwent major abdominal surgery at an academic institution over a 10-year period. The principal explanatory variable was preoperative thyroid hormone replacement. Primary outcomes were morbidity, mortality and length of stay.

RESULTS

2700 patients were identified. On multivariate analysis correcting for established predictors of operative morbidity, patients on preoperative thyroid replacement had a 1.5- fold increased risk of serious morbidity(p ​= ​0.01), and a 1.7- fold greater risk for serious sepsis(p ​= ​0.04). Thyroid replacement was associated with longer length of stay(p ​< ​0.001). While there was a high degree of missing data for surgical approach (31.1 ​% missing data), results suggest that patients on thyroid hormone replacement were more likely to undergo an open rather than minimally invasive surgery(p ​< ​0.01). Open surgery was associated with greater risk of serious morbidity(p ​= ​0.003) and longer length of stay(p ​< ​0.001).

CONCLUSIONS

Preoperative thyroid hormone replacement independently predicts operative morbidity and length of stay following major abdominal surgery.