Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. PATIENTS AND METHODS: We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. RESULTS: Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CONCLUSIONS: CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.

Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC).

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center. METHODS: A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs). RESULTS: A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012). CONCLUSIONS: ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.

Enhanced Recovery Protocol Versus Conventional Care in Patients Undergoing Esophagectomy for Cancer: Advantages in Clinical and Patient-Reported Outcomes.

BACKGROUND: This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared. METHODS: This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes. RESULTS: Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group. CONCLUSIONS: The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs.

Accelerated enhanced recovery after colon cancer surgery with discharge within one day after surgery: a systematic review.

BACKGROUND: Recent studies have demonstrated that accelerated enhanced recovery after colorectal surgery is feasible for specific patient populations. The accelerated enhanced recovery protocols (ERP) tend to vary, and the majority of studies included a small study population. This hampers defining the optimal protocol and establishing the potential benefits. This systematic review aimed to determine the effect of accelerated ERPs with intended discharge within one day after surgery. METHODS: PubMed (MEDLINE), Embase, Cochrane and Web of Science databases were searched using the following search terms: colon cancer, colon surgery, accelerated recovery, fast track recovery, enhanced recovery after surgery. Clinical trials published between January 2005 - February 2023, written in English or Dutch comparing accelerated ERPs to Enhanced Recovery After Surgery (ERAS) care for adult patients undergoing elective laparoscopic or robotic surgery for colon cancer were eligible for inclusion. RESULTS: Thirteen studies, including one RCT were included. Accelerated ERPs after colorectal surgery was possible as LOS was shorter; 14 h to 3.4 days, and complication rate varied from 0-35.7% and readmission rate was 0-17% in the accelerated ERP groups. Risk of bias was serious or critical in most of the included studies. CONCLUSIONS: Accelerated ERPs may not yet be considered the new standard of care as the current data is heterogenous, and data on important outcome measures is scarce. Nonetheless, the decreased LOS suggests that accelerated recovery is possible for selected patients. In addition, the complication and readmission rates were comparable to ERAS care, suggesting that accelerated recovery could be safe.

Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program.

OBJECTIVES: To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols. METHODS: We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006-12/30/2014) and after (1/1/2015-6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system. RESULTS: Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%. CONCLUSIONS: Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways.

National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy.

OBJECTIVE: To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). PATIENTS AND METHODS: From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. RESULTS: Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (ß -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51). CONCLUSIONS: Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.

Adrenal fast-track and enhanced recovery in retroperitoneoscopic surgery for primary aldosteronism improving patient outcome and efficiency.

PURPOSE: No data exist on perioperative strategies for enhancing recovery after posterior retroperitoneoscopic adrenalectomy (PRA). Our objective was to determine whether a multimodality adrenal fast-track and enhanced recovery (AFTER) protocol for PRA can reduce recovery time, improve patient satisfaction and maintain safety. METHODS: Thirty primary aldosteronism patients were included. Fifteen patients were treated with 'standard-of-care' PRA and compared with 15 in the AFTER protocol. The AFTER protocol contains: a preoperative information video, postoperative oral analgesics, early postoperative mobilisation and enteral feeding, and blood pressure monitoring at home. The primary outcome was recovery time. Secondary outcomes were length of hospital stay, postoperative pain and analgesics requirements, patient satisfaction, perioperative complications and quality of life (QoL). RESULTS: Recovery time was much shorter in both groups than anticipated and was not significantly different (median 28 days). Postoperative length of hospital stay was significantly reduced in AFTER patients (mean 32 vs 42 h, CI 95%, p = 0.004). No significant differences were seen in pain, but less analgesics were used in the AFTER group. Satisfaction improved amongst AFTER patients for time of admission and postoperative visit to the outpatient clinic. There were no significant differences in complication rates or QoL. CONCLUSION: Despite no difference in recovery time between the two groups, probably due to small sample size, the AFTER protocol led to shorter hospital stays and less analgesic use after surgery, whilst maintaining and even enhancing patient satisfaction for several aspects of perioperative care. Complication rates and QoL are comparable to standard-of-care.

The effect of enhanced recovery after surgery (ERAS) in renal surgery.

OBJECTIVE: To study the effect of ERAS on a textbook outcome (TO) after elective renal surgery. PATIENTS AND METHODS: Retrospective study of all patients who underwent a robot-assisted laparoscopic partial or radical nephrectomy or robot-assisted laparoscopic radical nephroureterectomy in Medisch Spectrum Twente (MST), Enschede, the Netherlands. In total, 277 patients were included. 66 patients from 2018 to 2021 (pre-ERAS group) and 211 patients from 2021 to 2023 (ERAS group). TO is a maximum of two nights in the hospital after surgery, no severe complications during or after surgery ≥ grade IIIb, no blood transfusions, no intensive care, no readmissions, and no mortality within 30 days after surgery. Comparisons were made between the pre-ERAS and ERAS groups using unpaired t-test, Mann-Whitney U test, the chi-squared test or Fisher's exact test. Multivariate logistic regression was used to adjust for possible confounding. RESULTS: TO was significantly (p = 0.005) better in the ERAS group (TO = 76.8%) compared to the pre-ERAS group (TO = 59.1%). Compared to a pre-ERAS patient, the adjusted odds ratio for achieving a TO as an ERAS patient is 2.1 (95% CI 1.15-3.78). CONCLUSIONS: The implementation of ERAS showed a positive effect on the TO of elective renal surgery patients.

Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use.

INTRODUCTION: Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS: We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS: One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS: Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.

Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments.

INTRODUCTION: While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS: This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS: Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS: ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Enhanced recovery after fetal spina bifida surgery: what is our global practice?

OBJECTIVE: Prenatal spina bifida closure results in improved outcomes for the child compared to postnatal surgery but is associated with significant maternal morbidity. Optimization of the perioperative care for women who underwent fetal spina bifida surgery could improve maternal and pregnancy outcomes. 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 aims to explore if fetal centers have implemented ERAS principles in this setting. Furthermore, we provide recommendations for the perioperative management of patients undergoing fetal spina bifida surgery. METHODS: Fifty-three 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 the center's compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for cesarean section, gynecologic oncology and colorectal surgery. Each item was scored 1 or 0 when the center did or did not comply with each principle, with a maximum score of 20. RESULTS: The questionnaire was completed by 46 centers in 17 countries (response rate 87%). Twenty-two centers (48%) exclusively perform open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offer both open and fetoscopic procedures and 10 (22%) use fetoscopy only. The perioperative management of patients undergoing fetoscopic and open surgery was highly similar. The median ERAS score was 12 (mean 12.5, SD 2.4, range 8-17). 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 achieved for preoperative carbohydrate loading (15%), postoperative nausea and vomiting prevention (33%), avoidance of overnight fasting (33%) and a 2-hour fasting period for clear fluids (20%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥11 days) hospital stay (12.8 ± 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 center volume. CONCLUSION: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardizing protocols according to ERAS principles may improve patient recovery, reduce maternal morbidity, and shorten hospital stay after fetal spina bifida surgery. This article is protected by copyright. All rights reserved.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review.

BACKGROUND: Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS: MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS: We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS: There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Challenges in Enhanced Recovery After Surgery (ERAS) research.

Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking 'Why is the patient still in hospital?' is the original premise for ERAS. Outcomes improve with increased compliance with recommended elements, but overcomplication of pathways can lead to cherry picking of elements that are convenient, resulting in 'partial ERAS'. As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources.

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials.

BACKGROUND: There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition. METHODS: The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis. RESULTS: We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.' CONCLUSIONS: A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Early enteral nutrition and mobilization following head and neck surgery with free flap reconstruction.

BACKGROUND: Perioperative management methods that reduce surgery-associated invasiveness and improve the quality of postoperative recovery are being promoted as enhanced recovery after surgery programs in various areas. Early enteral nutrition and mobilization are essential elements for enhanced recovery after surgery; however, their safety and feasibility are unclear in head and neck surgery with free tissue transfer reconstruction. This study aimed to clarify these uncertainties. METHODS: This is a retrospective before-after study. From 2018 to 2022, 187 and 173 patients received conventional management on or before April 2020 and early management on or after May 2020, respectively. The conventional management and early management groups received enteral nutrition and mobilization on postoperative days 2 and 1, respectively. The primary outcome for safety assessment was the incidence of complications. The secondary outcome was the compliance rate of conventional management or early management for feasibility assessment and the length of hospital stay. RESULTS: The clinical tumour-node-metastasis stage and American Society of Anesthesiologists physical status showed significant differences between the groups. In multivariable analysis, the early management group demonstrated a significantly lower incidence of treatment-required complication classified Clavien-Dindo Grade 2 and above (odds ratio = 0.57; 95% confidence interval = 0.31-0.92) and lower wound infection (odds ratio = 0.53; 95% confidence interval = 0.31-0.92). The early management group had lower compliance rate than the conventional management group; however, no statistically significant difference was observed (79.8% vs. 85.0%, P = 0.21). CONCLUSION: Early management is safe and feasible following head and neck surgery with free tissue transfer reconstruction. It could reduce the complication rate and is considered a useful postoperative management method.

The quality of guidelines on the pancreatic perioperative enhanced recovery after surgery: a systematic quality appraisal using AGREE II instrument.

PURPOSE: To evaluate the quality of guidelines on the pancreatic perioperative enhanced recovery after surgery both domestically and internationally, providing reference and reference for clinical practice. METHODS: Systemically retrieved in the guideline websites, professional association websites and databases, such as up to date, BMJ Best Practice, PubMed, Embase, The Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wan Fang Data, China Science and Technology Journal Database(VIP), China Biology Medicine disc (CBMdisc), Medlive, Guidelines International Network(GIN), National Guideline Clearinghouse(NGC), National Institute for Health and Care Excellence(NICE), Registered Nurses Association of Ontario(RNAO), Scottish Intercollegiate Guidelines Network(SIGN), Joanna Briggs Institute Library(JBI), including guidelines and expert consensus on enhanced postsurgical recovery in pancreatic surgery published as of December 20, 2023. The Appraisal of Guidelines for Research and Evaluation II(AGREE II) tool was applied to evaluate the quality of the guidelines by four assessors. RESULTS: This study included seven guidelines, all of which were rated as Grade B in terms of quality, with ICC coefficients ranging from 0.752 to 0.884, indicating a high level of consistency. CONCLUSION: When formulating guidelines in the future, it is recommended to use AGREE II as a reference, emphasizing the standardization of the guideline development process and methods, fully considering patients' values and preferences, focusing on the applicability of the guidelines, and striving to create high-quality evidence-based recommendations.

Postoperative outcomes in patients with diabetes after enhanced recovery thoracoscopic lobectomy.

BACKGROUND: Diabetes is considered a general surgical risk factor, but with few data from enhanced recovery (ERAS) otherwise known to improve outcome. Therefore, this study aimed to investigate postoperative outcomes of patients with diabetes who underwent video-assisted thoracoscopic surgery (VATS) lobectomy in an established ERAS setting. METHODS: We retrospectively analysed outcome data (hospital stay (LOS), readmissions, and mortality) from a prospective database with consecutive unselected ERAS VATS lobectomies from 2012 to 2022. Complete follow-up was secured by the registration system in East Denmark. RESULTS: We included 3164 patients of which 323 had diabetes, including 186 treated with insulin and antidiabetic medicine, 35 with insulin only and 102 with antidiabetic medicine only. The median LOS was 3 days, stable over the study period. There were no differences in terms of LOS, postoperative complications, readmissions or 30 days alive and out of hospital. Patients with diabetes had significantly higher 30- and 90-day mortality rates compared to those without diabetes (p < .001), but also had higher preoperative comorbidity. Preoperative HbA1c levels did not correlate with postoperative outcomes. CONCLUSION: In an ERAS setting, diabetes may not increase the risk for prolonged LOS, complications, and readmissions after VATS lobectomy, however with higher 30- and 90-day mortality probably related to more preoperative comorbidities.

Readmission after enhanced recovery video-assisted thoracoscopic surgery wedge resection.

BACKGROUND: Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection. METHODS: A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0-30 days postoperatively) and late readmission (occurring within 31-90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses. RESULTS: A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1-2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission. CONCLUSIONS: Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults.

BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Enhanced recovery after surgery and intestinal obstruction: A scoping review.

BACKGROUND: Acute intestinal obstruction is a blockage of the intestine which causes a range of clinical symptoms such as acute and severe abdominal pain, nausea, and obstipation. Intestinal obstruction is a medical emergency and can be life-threatening when left untreated. In cases where treatment involves emergency abdominal surgery, a multimodal perioperative care pathway (enhanced recovery after surgery ERAS) has shown to accelerate patient recovery after surgery, reduce hospital length of stay, and improve overall outcomes. The objective of this scoping review was to identify and synthesize the existing evidence regarding the implementation of ERAS components with a focus on postoperative components in patients undergoing surgery for acute intestinal obstruction. METHODS: This scoping review followed the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews framework. PubMed-Medline and Embase database were searched. RESULTS: The search identified 1860 studies of which 16 were included in the final analysis. All the studies were quantitative. Eleven studies used 10 or more ERAS interventions (range 10-28). The most common interventions were multimodal systemic analgesia, and the least common were the management of blood glucose and screening tools. CONCLUSION: This scoping review found that 56% (n = 9/16) of the identified studies used 10 or more ERAS interventions out of a possible 35. This review highlighted the need for studies on the ERAS emergency laparotomy guidelines.