Implementation of ERAS in pancreaticoduodenectomy in an Australian tertiary centre

BACKGROUND/OBJECTIVES

Recent studies have demonstrated that enhanced recovery after surgery (ERAS) protocols in pancreaticoduodenectomy (PD) may decrease morbidity and length of stay. This study aimed to critically assess the implementation of ERAS in patients who have undergone a PD in a tertiary centre.

METHODS

A retrospective cohort study of all patients who underwent a PD prior to ERAS, compared to following implementation were assessed. Outcome measures of length of stay, morbidity, mortality and readmission rates between the two groups were evaluated.

RESULTS

169 patients were included in the study (pre-ERAS, n = 29; stage 1, n = 14; stage 2, n = 53, stage 3, n = 73) with mean age of 64 ± 11.3 years. ERAS significantly increased the proportion of patients reaching the target length of stay of nine days (P = 0.017). It did not significantly impact overall mortality, morbidity, radiological intervention, reoperation or readmission (P > 0.05). ERAS did not have a significant impact on development of pancreatic fistula, ileus, infection or haemorrhage (P > 0.05). ERAS did significantly reduce rates of delayed gastric emptying (DGE) from 82.8% pre-ERAS to 49.0% in the stage 2 of implementation phase (P < 0.001).

CONCLUSIONS

The early implementation of the ERAS programme was safe although some obstacles were encountered. ERAS was beneficial in increasing the proportion of patients reaching the target length of stay without increasing readmission, reoperation, or morbidity. Our findings support the continued development of ERAS in PD in order to standardise care and improve patient recovery.

Faster recovery and bowel movement after early oral feeding compared to late oral feeding after upper GI tumor resections: a meta-analysis

Background

There were more than 1 million new cases of stomach cancer concerning oesophageal cancer, there were more than 600,000 new cases of oesophageal cancer in 2020. After a successful resection in these cases, the role of early oral feeding (EOF) was questionable, due to the possibility of fatal anastomosis leakage. It is still debated whether EOF is more advantageous compared to late oral feeding. Our study aimed to compare the effect of early postoperative oral feeding and late oral feeding after upper gastrointestinal resections due to malignancy.

Methods

Two authors performed an extensive search and selection of articles independently to identify randomized control trials (RCT) of the question of interest. Statistical analyses were performed including mean difference, odds ratio with 95% confidence intervals, statistical heterogeneity, and statistical publication bias, to identify potential significant differences. The Risk of Bias and the quality of evidence were estimated.

Results

We identified 6 relevant RCTs, which included 703 patients. The appearance of the first gas (MD = -1.16; p = 0.009), first defecation (MD = -0.91; p < 0.001), and the length of hospitalization (MD = -1.92; p = 0.008) favored the EOF group. Numerous binary outcomes were defined, but significant difference was not verified in the case of anastomosis insufficiency (p = 0.98), pneumonia (p = 0.88), wound infection (p = 0.48), bleeding (p = 0.52), rehospitalization (p = 0.23), rehospitalization to the intensive care unit (ICU) (p = 0.46), gastrointestinal paresis (p = 0.66), ascites (p = 0.45).

Conclusion

Early postoperative oral feeding, compared to late oral feeding has no risk of several possible postoperative morbidities after upper GI surgeries, but has several advantageous effects on a patient's recovery.

Systematic Review Registration

identifier, CRD 42022302594.

Preparing enhanced recovery after surgery for implementation in pediatric populations

Standardization in perioperative care has led to major improvements in surgical outcomes during the last two decades. Enhanced recovery after surgery (ERAS) programs are one example of a clinical pathway impacting both surgical outcomes and efficiency of care, but these programs have not yet been widely adapted for surgery in children. In adults, ERAS pathways have been shown to reduce length of stay, reduce complication rates, and improve patient satisfaction. These pathways improve outcomes through standardization of existing evidence-based best practices. Currently, the direct evidence for adapting ERAS pathways to pediatric surgery patients is limited. Challenges for implementation of ERAS programs for children include lack of direct translatability of adult evidence as well as varying levels acceptability of ERAS principles among pediatric providers and patients' families. We describe our newly implemented ERAS program for pediatric colorectal surgery patients in an era of limited direct evidence and discuss what further issues need to be addressed for broader implementation of pediatric ERAS pathways.

LEVEL OF EVIDENCE

Level 5.

The roles of ERAS during cell lineage specification of mouse early embryonic development

Eras encodes a Ras-like GTPase protein that was originally identified as an embryonic stem cell-specific Ras. ERAS has been known to be required for the growth of embryonic stem cells and stimulates somatic cell reprogramming, suggesting its roles on mouse early embryonic development. We now report a dynamic expression pattern of Eras during mouse peri-implantation development: its expression increases at the blastocyst stage, and specifically decreases in E7.5 mesoderm. In accordance with its expression pattern, the increased expression of Eras promotes cell proliferation through controlling AKT activation and the commitment from ground to primed state through ERK activation in mouse embryonic stem cells; and the reduced expression of Eras facilitates primitive streak and mesoderm formation through AKT inhibition during gastrulation. The expression of Eras is finely regulated to match its roles in mouse early embryonic development during which Eras expression is negatively regulated by the β-catenin pathway. Thus, beyond its well-known role on cell proliferation, ERAS may also play important roles in cell lineage specification during mouse early embryonic development.