International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative.

OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery.

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.

Pectoral block versus paravertebral block: a systematic review, meta-analysis and trial sequential analysis.

BACKGROUND: Pectoral (PECs) block was first described by Blanco et al for postoperative analgesia in breast surgery. It was proposed to be an easier and safer alternative to thoracic epidural or paravertebral block (PVB). In this systematic review and meta-analysis, we compare the perioperative analgesic efficacy and adverse events of PECs block and PVB. METHODS: We systematically searched PubMed, Central, EMBASE, CINAHL, Google Scholar, Web of Science citation index, US clinical trials register, Wanfang database, as well as recent conference abstracts, for clinical studies comparing the two techniques. Analgesic efficacy was assessed according to the time to first rescue analgesia and 24 hours opioid consumption. Adverse events from the trials were recorded and reported descriptively. RESULTS: The literature search was last updated on 20 February 2020. We identified a total of 10 randomized controlled trials (RCTs) comparing PECs to PVB with 252 and 250 patients, respectively. There was no difference in 24 hours opioid consumption between PECs and PVB. There was no significant difference in the time to rescue analgesia between the two cohorts. The most common adverse event noted was postoperative nausea and vomiting). Trial sequence analysis indicate that further studies are unlikely to alter the conclusion regarding opioid requirement. CONCLUSION: Our systematic review suggests that PECs and PVB are comparable in postoperative analgesia efficacy for mastectomy, and further studies are unlikely to alter the conclusion. The choice of technique should, therefore, be based on practitioner skill and institutional guidelines. PROSPERO REGISTRATION NUMBER: CRD42020165137.

Demonstrating Value: A Case Study of Enhanced Recovery.

An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.